Wearable device with bridge portion

ABSTRACT

The present disclosure relates to a wearable device with a bridge portion and systems/methods relating to the device. Preferred embodiments may include two flexible wings and a bridge connecting the two wings. In some embodiments, the upper surface of the bridge can be non-adhesive and uncoupled to the flexible wing such that the flexible wing can be decoupled from the bridge when the adhesive is adhered to the surface of a user. The bridge can be narrower in some portions, and extend around the housing of the monitor. The bridge can extend beneath the housing and bisect the two flexible wings.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.17/805,622, filed on Jun. 6, 2022, which is a continuation of U.S.patent application Ser. No. 17/396,130, filed on Aug. 6, 2021, whichclaims priority from provisional U.S. Pat. App. No. 63/062,293, filed onAug. 6, 2020, which is hereby incorporated by reference in its entirety.

BACKGROUND

For purposes of this disclosure, certain aspects, advantages, and novelfeatures of various embodiments are described herein. It is to beunderstood that not necessarily all such advantages may be achieved inaccordance with any particular embodiment. Thus, various embodiments maybe or carried out in a manner that achieves one advantage or group ofadvantages as taught herein without necessarily achieving otheradvantages as may be taught or suggested herein.

FIELD OF THE INVENTION

Disclosed herein are materials, devices, methods, and systems formonitoring physiological signals. For example, such physiologicalsignals may include heart signals, such as an electrocardiogram signal.

DESCRIPTION OF THE RELATED ART

Abnormal heart rhythms, or arrhythmias, may cause various types ofsymptoms, such as loss of-consciousness, palpitations, dizziness, oreven death. An arrhythmia that causes such symptoms is often anindicator of significant underlying heart disease. It is important toidentify when such symptoms are due to an abnormal heart rhythm, sincetreatment with various procedures, such as pacemaker implantation orpercutaneous catheter ablation, can successfully ameliorate theseproblems and prevent significant symptoms and death. For example,monitors such as Holter monitors and similar devices are currently inuse to monitor heart rhythms.

BRIEF SUMMARY OF EMBODIMENTS

Embodiments described herein are directed to a physiological monitoringdevice that may be worn continuously and comfortably by a human oranimal subject for at least one week or more and more typically two tothree weeks or more. In one embodiment, the device is specificallydesigned to sense and record cardiac rhythm (for example,electrocardiogram, ECG) data, although in various alternativeembodiments one or more additional physiological parameters may besensed and recorded. Such physiological monitoring devices may include anumber of features to facilitate and/or enhance the patient experienceand to make diagnosis of cardiac arrhythmias more accurate and timely.

In some embodiments, an electronic device for monitoring physiologicalsignals in a mammal comprises: at least two flexible wings extendinglaterally from a housing, wherein the flexible wings comprise a firstset of materials which enable the wings to conform to a surface of themammal and the housing comprises a second set of materials; a printedcircuit board assembly housed within the housing, wherein the housing isconfigured to prevent deformation of the printed circuit board inresponse to movement of the mammal; at least two electrodes embeddedwithin the flexible wings, the electrodes configured to provideconformal contact with the surface of the mammal and to detect thephysiological signals of the mammal; at least two electrode tracesembedded within the wings and mechanically decoupled from the housing,the electrode traces configured to provide conformal contact with thesurface of the mammal and transmit electrical signals from theelectrodes to the printed circuit board assembly; and, at least onehinge portion connecting the wings to the housing, the hinge portionsconfigured to flex freely at the area where it is joined to the housing.

In certain embodiments, each wing may comprise an adhesive. Inembodiments, the electrodes can be in the same plane as the adhesive. Incertain embodiments, each wing comprises at least one rim, wherein therim is thinner than an adjacent portion of each wing. The housing mayfurther comprise dimples or grooves configured to allow for airflowbetween the housing and the surface of the mammal. In certainembodiments, the rim is configured to prevent the release of a portionof the wing from the surface of the mammal. In some embodiments, anelectronic device for monitoring physiological systems may comprise ameasuring instrument configured to detect motion signals in at least oneaxis. This measuring instrument may be an accelerometer that can beconfigured to detect motion signals in three axes.

In embodiments, the motion signals can be collected in time with thephysiological signals. In certain embodiments, a motion artifact isidentified when the physiological signals and the motion signals match.Further embodiments may call for an event trigger coupled to the printedcircuit board assembly. In some embodiments, the event trigger input issupported by the housing so as to prevent mechanical stress on theprinted circuit board when the trigger is activated which, in turn, canreduce a source of artifact in the recorded signal. The event triggermay be concave or convex and larger than a human finger such that theevent trigger is easily located. In certain embodiments, the electrodetraces are configured to minimize signal distortion during movement ofthe mammal. In particular embodiments, gaskets may be used as a meansfor sealable attachment to the housing.

In certain embodiments, a method for monitoring physiological signals ina mammal may comprise: attaching an electronic device to the mammal,wherein the device comprises: at least two electrodes configured todetect physiological signals from the mammal, at least one measuringinstrument configured to detect secondary signals, and at least twoelectrode traces connected to the electrodes and a housing; and,comparing the physiological signals to the secondary signals to identifyan artifact.

In certain embodiments, identification of artifacts comprises acomparison between the frequency spectrum of the physiological signalsand the frequency spectrum of the secondary signals. In embodiments, thesecondary signals comprise motion signals that may be used to derive theactivity and position of the mammal. In certain embodiments, thesecondary signals are collected in three axes. In some embodiments, atertiary signal may also be collected. In certain embodiments, thesecondary signals comprise information about the connection between theelectronic device and the mammal. In some embodiments, the secondarysignals may be used to detect when the mammal is sleeping.

In some embodiments, a method of removing and replacing portions of amodular physiological monitoring device may comprise: applying thedevice described above to a mammal for a period of time greater than 7days and collecting physiological data; using the device to detect afirst set of physiological signals; removing the device from the surfaceof the mammal; removing a first component from the device; and,incorporating the first component into a second physiological monitoringdevice, the second physiological monitoring device configured to detecta second set of physiological signals.

In some embodiments, the first component is electrically connected toother device components without the use of a permanent connection. Insome embodiments, the device may further comprise spring connections. Incertain embodiments, the first component may be preserved for a seconduse by a housing to prevent damage. In particular embodiments, the firstcomponent is secured within a device by a mechanism that is capable ofre-securing a second component once the first component is removed.

Certain embodiments may concern a system for inferring cardiac rhythminformation from time-series data of heart beat intervals, as obtainedfrom either consumer wearable or medical device products. A furtheraspect concerns improvements to the system to enable cardiac rhythminformation to be inferred in a more robust and/or timely manner throughthe use of additional sources of data. This additional data may includesummary statistics or specific signal features derived from an ECG, useractivity time series data derived from an accelerometer, informationrelated to user state, or information related to the day/time of therecording.

In certain embodiments, a system for selective transmission ofelectrocardiographic signal data from a wearable medical sensor, whereQRS refers to the three fiducial points of an ECG recording at the timeof ventricle depolarization, may comprise:

a. A wearable medical sensor incorporating a QRS detector that producesa real-time estimate of each R peak location in the ECG

b. Transmission of an R-R interval time series together with an onsettime stamp from the sensor to a smartphone or internet-connected gatewaydevice, according to a predefined schedule

c. Transmission of the R-R interval time series and the onset time stampfrom the smartphone or internet-connected gateway device to a server

d. Server-side algorithmic inference of the most probable rhythms andtheir onset/offset times from the R-R interval time series data

e. Filtering the list of inferred heart rhythms according to specificfilter criteria, such that only inferred rhythms matching the givencriteria are retained after filtering

f. Transmission of the onset/offset time for each rhythm remaining afterfiltering, from the server to the smartphone or internet-connectedgateway device

g. Transmission of the onset/offset time for each rhythm remaining afterfiltering, from the smartphone or internet-connected gateway device tothe wearable sensor

h. Transmission of the section of recorded ECG corresponding to eachonset-offset time pair from the sensor to the smartphone orinternet-connected gateway device

i. Transmission of the section of recorded ECG corresponding to eachonset-offset time pair from the smartphone or internet-connected gatewaydevice to the server

The rhythm filter criteria may be specified by a physician or othermedical professional prior to the use of the wearable sensor by apatient. In other embodiments, the rhythm filter criteria are dynamicand can be updated during the use of the system according to predefinedrules. In some embodiments, these predefined rules may describe anadjustment to the filter criteria based on previous findings during useof the system. In some embodiments, the onset and offset time for eachinferred rhythm may be adjusted such that the resulting duration foreach rhythm is less than a given maximum permissible duration. Computedconfidence measures may be an input to the rhythm filter criteria. Insome embodiments, the system comprises inferring cardiac rhythminformation from R-R interval time series data. In certain embodiments,the cardiac rhythm inference system is implemented as a cloud serviceaccessible via an API.

In certain embodiments, the cardiac rhythm inference system is providedthrough a software library that can be incorporated into a standaloneapplication. The R-R interval values may be are estimated from aphotoplethysmography signal.

In certain embodiments of a method for inferring cardiac rhythminformation, the cardiac rhythm inference system computes a confidencescore for each type of cardiac rhythm, the method comprising:

a. Computing the frequency and duration of each cardiac rhythm typeinferred from the collection of R-R interval time series data for thegiven user

b. Estimating a confidence statistic for each rhythm type based on theinferred frequency and duration of the rhythm across the collection ofR-R interval time series for the given user

c. Evaluating if the confidence statistic for each inferred rhythmexceeds a pre-determined threshold value

d. Providing rhythm information back to the calling software only forthose inferred rhythms for which the confidence statistic exceeds thethreshold value

In certain embodiments, the cardiac rhythm inference system acceptsadditional sources of data, comprising one or more of:

e. User activity time series data measured by an accelerometer

f. Information on the specific day and time of each R-R interval timeseries recording

g. Information on user age, gender, clinical indication for monitoring,pre-existing medical conditions, medication information, and medicalhistory

h. ECG signal features and summary statistics, such as the mean, median,standard deviation or sum of the ECG signal sample values within a giventime period

i. A confidence rating provided by the measurement device to indicatethe quality of heart beat estimation, for example, for each beat or forsequential time periods.

j. Intra-beat interval measurements

In embodiments, a system for monitoring cardiac signal data, comprises:

wearable medical sensor, the wearable medical sensor configured todetect cardiac signals from a mammal and estimate the R-peak locationwithin the cardiac signal;

wherein the wearable medical sensor is configured to transmit an R-Rinterval time series and a time stamp to an intermediary device, theintermediary device configured to further transmit the R-R interval timeseries and time stamp to a server;

wherein the server is configured to infer the most probable rhythms andtheir onset/offset times from the R-R interval time series and timestamp, the server configured to filter the most probable rhythmsaccording to a first criteria into a filtered data set;

wherein the server is configured to transmit the filtered data set backto the wearable sensor via the intermediary device; and

wherein the sensor transmits the full resolution cardiac signal to theserver for a time period surrounding each of the filtered events.

In certain embodiments, a system for monitoring cardiac signal datacomprises:

a server configured to communicate with a wearable sensor, the wearablesensor configured to detect cardiac signals from a mammal and estimatethe R peak location within the cardiac signal;

wherein the wearable sensor is configured to transmit an R-R intervaltime series and a time stamp to the server;

wherein the server is configured to infer the most probable rhythms andtheir onset/offset times from the R-R interval time series and timestamp, the server configured to filter the most probable rhythmsaccording to a first criteria into a filtered data set; and

wherein the server is configured to transmit a summary of the filtereddata.

In particular embodiments, a server for monitoring cardiac signal data,comprises:

a portal configured to communicate with a wearable sensor, the wearablesensor configured to detect cardiac signals from a mammal and estimatethe R peak location within the cardiac signal, wherein the wearablesensor is configured to transmit an R-R interval time series and a timestamp to an intermediary device, the intermediary device configured tofurther transmit the R-R interval time series and time stamp to aserver;

a processor configured to infer the most probable rhythms and theironset/offset times from the R-R interval time series and time stamp, theprocessor configured to filter the most probable rhythms according to afirst criteria into a filtered data set; and

wherein the server is configured to transmit a summary of the filtereddata set.

In embodiments, a non-transitory storage medium havingcomputer-executable instructions stored thereon, the computer-executableinstructions readable by a computing system comprising one or morecomputing devices, wherein the computer-executable instructions areexecutable on the computing system in order to cause the computingsystem to perform operations comprises: receiving, by a computing systemthrough a communication link, physiological sensor data generated by apatient monitoring device, the physiological sensor data associated witha first patient; analyzing, by the computing system, the physiologicalsensor data to determine whether one or more points in the physiologicaldata that are likely indicative of one or more predetermined set ofconditions; and after determining that at least one of the one or morepoints in the physiological data is likely indicative of at least one ofthe one or more predetermined set of conditions, generating, by thecomputing system, an electronic data package for transmission to thepatient monitoring device, the electronic data package includinglocation data regarding the at least one of the one or more points inthe physiological sensor data that are likely indicative of the at leastone of the one or more predetermined set of conditions.

In certain embodiments, the physiological sensor data may comprise asampling of interval data measured from the recorded signal data, thesampling of interval data of a data size less than the recorded signaldata.

In particular embodiments, a system for monitoring physiological signalsin a mammal may comprise: a wearable adhesive monitor configured todetect and record cardiac rhythm data from a mammal, the wearableadhesive monitor configured to extract a feature from the cardiac rhythmdata; and wherein the wearable adhesive monitor is configured totransmit the feature to a processing device, the processing deviceconfigured to analyze the feature, identify locations of interest, andtransmit the locations of interest back to the wearable adhesivemonitor.

In certain embodiments, a system for assessing physiological sensor datafrom a patient monitoring device comprises: a computer processor andnon-transitory computer-readable media combined with the computerprocessor configured to provide a program that includes a set ofinstructions stored on a first server, the set of instructions beingexecutable by the computer processor, and further configured to executea sensor data inference module of the program; the sensor data inferencemodule of the program storing instructions to: receive physiologicalsensor data generated by a patient monitoring device, the physiologicalsensor data associated with a first patient; analyze the physiologicalsensor data to determine whether one or more points in the physiologicaldata that are likely indicative of one or more predetermined set ofconditions; and after determining that at least one of the one or morepoints in the physiological data is likely indicative of at least one ofthe one or more predetermined set of conditions, generating anelectronic data package for transmission to the patient monitoringdevice, the electronic data package including location data regardingthe at least one of the one or more points in the physiological sensordata that are likely indicative of the at least one of the one or morepredetermined set of conditions.

In certain embodiments, a computerized method may comprise: accessingcomputer-executable instructions from at least one computer-readablestorage medium; and executing the computer-executable instructions,thereby causing computer hardware comprising at least one computerprocessor to perform operations comprising: receiving, by a servercomputer through a communication link, physiological sensor datagenerated by a patient monitoring device, the physiological sensor dataassociated with a first patient; analyzing, by the server computer, thephysiological sensor data to determine whether one or more points in thephysiological data that are likely indicative of one or morepredetermined set of conditions; and after determining that at least oneof the one or more points in the physiological data is likely indicativeof at least one of the one or more predetermined set of conditions,generating, by the server computer, an electronic data package fortransmission to the patient monitoring device, the electronic datapackage including location data regarding the at least one of the one ormore points in the physiological sensor data that are likely indicativeof the at least one of the one or more predetermined set of conditions.

These and other aspects and embodiments of the invention are describedin greater detail below, with reference to the drawing figures.

BRIEF DESCRIPTION OF THE DRAWINGS

FIGS. 1A and 1B are perspective and exploded profile views,respectively, of a physiological monitoring device, according to oneembodiment.

FIGS. 2A and 2B are top perspective and bottom perspective views,respectively, of a printed circuit board assembly of the physiologicalmonitoring device, according to one embodiment.

FIGS. 3A, 3B, 3C, 3D, and 3E are perspective and exploded views of aflexible body and gasket of the physiological monitoring device,according to one embodiment.

FIGS. 4A-4E schematically depict examples of adhesive layers comprisingdifferent arrangements of channels. FIG. 4A schematically illustrates atop view of a portion of adhesive layer comprising vertical channels.FIG. 4B schematically illustrates an adhesive layer comprising columnchannels. FIGS. 4C and 4D schematically illustrate examples of anadhesive layer comprising lattice networks of channels. FIG. 4Eschematically illustrates an adhesive layer comprising radiallyspiraling channels.

FIGS. 5A-5H schematically illustrate another embodiment of aphysiological monitoring device. FIG. 5A schematically depicts a bottomview the physiological monitoring device, including the horizontaldisposition of various constituent layers. FIG. 5B illustrates a supportlayer forming the main structure of the flexible body. FIG. 5Cillustrates a close-up of the inset A depicted in FIG. 5B. FIG. 5Dillustrates a central portion of the support layer configured to floatover the skin of the subject between hinge lines of the flexible body.FIG. 5E illustrates perforated layers (e.g., perforated PET layers)comprising apertures for providing structural support to the wings whilepermitting moisture transmission according to some embodiments. FIG. 5Fillustrates a close-up view of the inset A depicted in FIG. 5E. FIG. 5Gdepicts two adhesive layers. FIG. 5H depicts a perspective view of thephysiological monitoring device.

FIGS. 6A-6H illustrate various views of embodiments of a physiologicalmonitoring device. FIG. 6A depicts a perspective view, FIG. 6B shows atop view, FIG. 6C shows a bottom view, and FIG. 6D1 depicts a side view.FIG. 6D2 depicts a side view of a ridge configured for sealing the topand bottom portions of the housing. FIGS. 6E and 6F show a bottom and atop view of the physiological monitoring device with the layersillustrated transparently, to provide visualization through the device.FIGS. 6G and 6H illustrate exploded views of the various components ofthe physiological monitoring device.

FIG. 7A schematically illustrates the profile of a substrate layer of aflexible body having hinge lines between which the flexible body isconfigured to float. FIGS. 7B-7D schematically illustrate variousexamples of configurations of adhesive layers comprising bridgesdesigned to be coupled to the flexible body and to extend underneath thehousing. FIG. 7E schematically illustrates bottom views of physiologicalmonitoring devices comprising a single adhesive layer having a“headphone” shaped configuration and comprising a bridge portion. FIG.7F depicts an embodiment of a wing shape.

FIGS. 8A-8J schematically illustrate embodiments of a physiologicalmonitoring device having a rigid body and traces coupled to the topsurface of a flexible body. FIGS. 8A-8J illustrate the various steps ofassembling the physiological monitoring device and/or replacing theflexible body, including the adhesive layer, of the physiologicalmonitoring device.

FIG. 9 is a view of a top portion and a bottom portion of a housing ofthe physiological monitoring device, according to one embodiment.

FIGS. 10A and 10B provide a perspective view of a battery holder of thephysiological monitoring device, according to one embodiment.

FIGS. 11A and 11B are cross sectional views of the physiologicalmonitoring device, according to one embodiment.

FIG. 12 is an exploded view of the physiological monitoring deviceincluding a number of optional items, according to one embodiment.

FIGS. 13A and 13B are perspective views of two people wearing thephysiological monitoring device, illustrating how the device bends toconform to body movement and position, according to one embodiment.

FIGS. 14A, 14B, 14C, 14D, 14E, and 14F illustrate various steps forapplying the physiological monitor to a patient's body, according to oneembodiment.

FIG. 15 illustrates a schematic diagram of an embodiment of a cardiacrhythm inference service.

DETAILED DESCRIPTION OF EMBODIMENTS

The following description is directed to a number of variousembodiments. The described embodiments, however, may be implementedand/or varied in many different ways. For example, the describedembodiments may be implemented in any suitable device, apparatus, orsystem to monitor any of a number of physiological parameters. Forexample, the following discussion focuses primarily on long-term,patch-based cardiac rhythm monitoring devices. In one alternativeembodiment, a physiological monitoring device may be used, for example,for pulse oximetry and diagnosis of obstructive sleep apnea. The methodof using a physiological monitoring device may also vary. In some cases,a device may be worn for one week or less, while in other cases, adevice may be worn for at least seven days and/or for more than sevendays, for example between fourteen days and twenty-one days or evenlonger. Many other alternative embodiments and applications of thedescribed technology are possible. Thus, the following description isprovided for exemplary purposes only. Throughout the specification,reference may be made to the term “conformal.” It will be understood byone of skill in the art that the term “conformal” as used herein refersto a relationship between surfaces or structures where a first surfaceor structure adapts to the contours of a second surface or structure.

Since abnormal heart rhythms or arrhythmias can often be due to other,less serious causes, a key challenge is to determine when any of thesesymptoms are due to an arrhythmia. Oftentimes, arrhythmias occurinfrequently and/or episodically, making rapid and reliable diagnosisdifficult. As mentioned above, currently, cardiac rhythm monitoring isprimarily accomplished through the use of devices, such as Holtermonitors, that use short-duration (less than 1 day) electrodes affixedto the chest. Wires connect the electrodes to a recording device,usually worn on a belt. The electrodes need daily changing and the wiresare cumbersome. The devices also have limited memory and recording time.Wearing the device interferes with patient movement and often precludesperforming certain activities while being monitored, such as bathing.Further, Holter monitors are capital equipment with limitedavailability, a situation that often leads to supply constraints andcorresponding testing delays. These limitations severely hinder thediagnostic usefulness of the device, the compliance of patients usingthe device, and the likelihood of capturing all important information.Lack of compliance and the shortcomings of the devices often lead to theneed for additional devices, follow-on monitoring, or other tests tomake a correct diagnosis.

Current methods to correlate symptoms with the occurrence ofarrhythmias, including the use of cardiac rhythm monitoring devices,such as Holter monitors and cardiac event recorders, are often notsufficient to allow an accurate diagnosis to be made. In fact, Holtermonitors have been shown to not lead to a diagnosis up to 90% of thetime (“Assessment of the Diagnostic Value of 24-Hour AmbulatoryElectrocardiographic Monitoring”, by DE Ward et al. Biotelemetry PatientMonitoring, vol. 7, published in 1980).

Additionally, the medical treatment process to actually obtain a cardiacrhythm monitoring device and initiate monitoring is typically verycomplicated. There are usually numerous steps involved in ordering,tracking, monitoring, retrieving, and analyzing the data from such amonitoring device. In most cases, cardiac monitoring devices used todayare ordered by a cardiologist or a cardiac electrophysiologist (EP),rather than the patient's primary care physician (PCP). This is ofsignificance since the PCP is often the first physician to see thepatient and determine that the patient's symptoms could be due to anarrhythmia. After the patient sees the PCP, the PCP will make anappointment for the patient to see a cardiologist or an EP. Thisappointment is usually several weeks from the initial visit with thePCP, which in itself leads to a delay in making a potential diagnosis aswell as increases the likelihood that an arrhythmia episode will occurand go undiagnosed. When the patient finally sees the cardiologist orEP, a cardiac rhythm monitoring device will usually be ordered. Themonitoring period can last 24 to 48 hours (Holter monitor) or up to amonth (cardiac event monitor or mobile telemetry device). Once themonitoring has been completed, the patient typically must return thedevice to the clinic, which itself can be an inconvenience. After thedata has been processed by the monitoring company or by a technicianon-site at a hospital or office, a report will finally be sent to thecardiologist or EP for analysis. This complex process results in fewerpatients receiving cardiac rhythm monitoring than would ideally receiveit.

To address some of these issues with cardiac monitoring, the assignee ofthe present application developed various embodiments of a small,long-term, wearable, physiological monitoring device. One embodiment ofthe device is the Zio® Patch. Various embodiments are also described,for example, in U.S. Pat. Nos. 8,150,502, 8,160,682 8,244,335,8,560,046, 8,538,503, 9,173,670, and 9,597,004, and U.S. Pat. Pub. No.2018/0289274 A1, the full disclosures of which are hereby incorporatedherein by reference. Generally, the physiological patch-based monitorsdescribed in the above references fit comfortably on a patient's chestand are designed to be worn for at least one week and typically two tothree weeks. The monitors detect and record cardiac rhythm signal datacontinuously while the device is worn, and this cardiac rhythm data isthen available for processing and analysis.

These smaller, long-term, patch-based physiological monitoring devicesprovide many advantages over prior art devices. At the same time,further improvements are desired. One of the most meaningful areas forimprovement is to offer more timely notice of critical arrhythmias tomanaging clinicians. The hallmark of these initial embodiments wasthat—for reasons of performance, compliance and cost—the device onlyrecorded information during the extended wear period, with analysis andreporting occurring after the recording completed. Thus, a desirableimprovement would be to add the capability of either real-time or timelyanalysis of the collected rhythm information. While diagnostic monitorswith such timely reporting capabilities currently exist, they requireone or more electrical components of the system to be either regularlyrecharged or replaced. These actions are associated with reduced patientcompliance and, in turn, reduced diagnostic yield. As such, a key areaof improvement is to develop a physiologic monitor that can combinelong-term recording with timely reporting without requiring batteryrecharging or replacement.

Patient compliance and device adhesion performance are two factors thatgovern the duration of the ECG record and consequently the diagnosticyield. Compliance can be increased by improving the patient's wearexperience, which is affected by wear comfort, device appearance, andthe extent to which the device impedes the normal activities of dailyliving. Given that longer ECG records provide greater diagnostic yieldand hence value, improvements to device adhesion and patient complianceare desirable.

Signal quality is important throughout the duration of wear, but may bemore important where the patient marks the record, indicating an area ofsymptomatic clinical significance. Marking the record is most easilyenabled through a trigger located on the external surface of the device.However, since the trigger may be part of a skin-contacting platformwith integrated electrodes, the patient can introduce significant motionartifacts when feeling for the trigger. A desirable device improvementwould be a symptom trigger that can be activated with minimal additionof motion artifact.

Further, it is desirable for the device to be simple and cost effectiveto manufacture, enabling scalability at manufacturing as well as higherquality due to repeatability in process. Simplicity of manufacture canalso lead to ease of disassembly, which enables the efficient recoveryof the printed circuit board for quality-controlled reuse in anotherdevice. Efficient reuse of this expensive component can be important fordecreasing the cost of the diagnostic monitor.

There remain clinical scenarios where still longer-duration andlower-cost solutions may be a valuable addition to a portfolio ofcardiac ambulatory monitoring options. Inspiration for a potentialsolution to these needs can be found in the continuous heart ratesensing functionality that is increasingly being incorporated in avariety of consumer health and fitness products, including smart watchesand wearable fitness bands. Although continuous heart rate data can beused to provide the user with information about their general fitnesslevels, it is more both more challenging and valuable to use this datato provide meaningful information related to their health and wellness.For example, the ability to detect potential arrhythmias from continuousheart rate data would enable consumer devices incorporating heart ratesensing functionality to serve as potential screening tools for theearly detection of cardiac abnormalities. Such an approach could beclinically valuable in providing a long-term, cost-effective screeningmethod for at-risk populations, for example, heart failure patients atrisk for Atrial Fibrillation. Alternatively, this monitoring approachcould be helpful in the long-term titration of therapeutic drug dosagesto ensure efficaciousness while reducing side effects, for example, inthe management of Paroxysmal Atrial Fibrillation. Beyond cardiacarrhythmia detection, the appropriate analysis of heart rate informationcould also yield insight into sleep and stress applications.

Long-term ambulatory monitoring with a physiologic device, such as anadhesive patch, has a number of clinical applications, particularly whentimely information about the occurrence and duration of observedarrhythmias can be provided during the monitoring period. In terms ofprevalence, particularly as driven by an aging population, efficientlydetecting Atrial Fibrillation (AF) remains the most significantmonitoring need. This need is not just evident for patients presentingwith symptoms, but also given the increased risk of stroke associatedwith this arrhythmia for broader, population-based monitoring ofasymptomatic AF in individuals at risk due to one or more factors ofadvanced age, the presence of chronic illnesses like Heart Disease, oreven the occurrence of surgical procedures. For the latter group, bothperioperative and post-procedure monitoring can be clinically valuable,and not just for procedures targeted at arrhythmia prevention (forexample, the MAZE ablation procedure, or hybrid endo and epicardialprocedures, both for treatment of AF), but also for general surgeriesinvolving anesthesia. For some applications, the goal of ambulatorymonitoring for Atrial Fibrillation will sometimes be focused on thesimple binary question of whether AF did occur in a given time period.For example, monitoring a patient following an ablation procedure willtypically seek to confirm success, typically defined as the completelack of AF occurrence. Likewise, monitoring a patient post-stroke willbe primarily concerned with evaluating the presence of AtrialFibrillation.

However, even in those scenarios, if AF occurs, it may be clinicallymeaningful to evaluate additional aspects to better characterize theoccurrence, such as daily burden (% of time in AF each day), andduration of episodes (expressed, for example, as a histogram of episodeduration, or as the percentage of episodes that extend beyond aspecified limit, say six minutes), both either in absolute terms or incomparison to prior benchmarks (for example, from a baseline,pre-procedure monitoring result). Indeed, measuring daily AF burden,evaluating AF episode duration, and reviewing AF occurrence during sleepand waking periods, and evaluating the presence of AF in response to thedegree of a patient's physical movement can be important in a variety ofclinical scenarios, including evaluating the effectiveness of drug-basedtreatment for this arrhythmia.

Making this information available in a timely manner during themonitoring period could allow the managing physician to iterativelytitrate treatment, for example, by adjusting the dosage and frequency ofa novel oral anticoagulant drug (NOAC) until management was optimized. Afurther example of this management paradigm is for the patient to benotified of asymptomatic AF—either directly by the device throughaudible or vibration-based alert, through notification from anapplication connected to the device, or via phone, email or text-messagecommunication from the managing clinician—for the timely application ofa “pill in the pocket” for AF management.

The theme of timely management and/or intervention is certainly evidentin situations where clinically significant arrhythmias are observed, forexample, asymptomatic second-degree and complete Heart Block, extendedpauses, high-rate supraventricular tachycardias, prolonged ventriculartachycaridas, and ventricular fibrillation. For example, the clinicalscenario where an extended pause or complete heart block causes Syncopeis a particularly significant case where the availability of a timelyand dependable monitoring method could reduce or even eliminate the needfor in-hospital monitoring of at-risk patients. The theme can alsoextend to more subtle changes in morphology, for example, QTprolongation in response to medications, which has been shown to havesignificant cardiac safety implications. Timely awareness of suchprolongation could lead, for example, to early termination of clinicalstudies evaluating drug safety and effectiveness or, alternatively, toadjusting the dosage or frequency as a means to eliminate observedprolongation.

Physiological Monitoring Devices

Referring to FIGS. 1A and 1B, perspective and exploded profile views ofone embodiment of a physiological monitoring device 100 are provided. Asseen in FIG. 1A, physiological monitoring device 100 may include aflexible body 110 coupled with a watertight, housing 115. As will beunderstood by one of skill in the art, the housing as described hereinand throughout this specification, may be constructed from rigid orflexible materials, thereby rendering the housing rigid, such as toresist deformation or soft such as to flex and/or deform with force.Flexible body 110 (which may be referred to as “flexible substrate” or“flexible construct”) typically includes two wings 130, 131, whichextend laterally from housing 115, and two flexible electrode traces311, 312, each of which is embedded in one of wings 130, 131. Eachelectrode trace 311, 312 is coupled, on the bottom surface of flexiblebody 110, with a flexible electrode (not visible in FIG. 1A). Theelectrodes are configured to sense heart rhythm signals from a patientto which monitoring device 100 is attached. Electrode traces 311, 312then transmit those signals to electronics (not visible in FIG. 1A)housed in housing 115. Housing 115 also typically contains a powersource, such as one or more batteries.

The combination of a highly flexible body 110, including flexibleelectrodes and electrode traces 311, 312, with a very housing 115 mayprovide a number of advantages. A key advantage is high fidelity signalcapture. The highly conformal and flexible wings 130, 131, electrodesand traces 311, 312 limit the transmission of external energy to theelectrode-skin interface. If motion is imparted to the housing 115, forexample, the system of conformal adhesion to the skin limits the extentto which that motion affects the monitored signal. Flexible electrodetraces 311, 312 generally may help provide conformal contact with thesubject's skin and may help prevent electrodes 350 (electrodes 350 arenot visible in FIG. 1 , but are visible in FIG. 6A described below) frompeeling or lifting off of the skin, thereby providing strong motionartifact rejection and better signal quality by minimizing transfer ofstress to electrodes 350. Furthermore, flexible body 110 includes aconfiguration and various features that facilitate comfortable wearingof device 100 by a patient for fourteen (14) days or more withoutremoval. Housing 115, which typically does not adhere to the patient inthe embodiments described herein, includes features that lend to thecomfort of device 100. Hinge portions 132 are relatively thin, even moreflexible portions of flexible body 110. They allow flexible body 110 toflex freely at the area where it is joined to housing 115. Thisflexibility enhances comfort, since when the patient moves, housing 115can freely lift off of the patient's skin. Electrode traces 311, 312 arealso very thin and flexible, to allow for patient movement withoutsignal distortion.

Referring now to FIG. 1B, a partially exploded view of physiologicalmonitoring device 100 illustrates component parts that make up, and thatare contained within, housing 115 in greater detail. In this embodiment,housing 115 includes an upper housing member 140, which detachablycouples with a lower housing member 145. Sandwiched between upperhousing member 140 and lower housing member 145 are an upper gasket 370,and a lower gasket 360 (not visible on FIG. 1B but just below uppergasket 370). Gaskets 370, 360 help make housing 115 watertight whenassembled. A number of components of monitoring device 100 may be housedbetween upper housing member 140 and lower housing member 145. Forexample, in one embodiment, housing 115 may contain a portion offlexible body 110, a printed circuit board assembly (PCBA) 120, abattery holder 150, and two batteries 160. Printed circuit boardassembly 120 is positioned within housing 115 to contact electrodetraces 311, 312 and batteries 160. In various embodiments, one or moreadditional components may be contained within or attached to housing115. Some of these optional components are described further below, inreference to additional drawing figures.

Battery holder 150, according to various alternative embodiments, mayhold two batteries (as in the illustrated embodiment), one battery, ormore than two batteries. In other alternative embodiments, other powersources may be used. In the embodiment shown, battery holder 150includes multiple retain tabs 153 for holding batteries 160 in holder150. Additionally, battery holder 150 includes multiple feet 152 toestablish correct spacing of batteries 160 from the surface of PCBA 120and ensure proper contact with spring fingers and/or contacts 235 and236. Spring fingers 235 and 236 are used in this embodiment rather thansoldering batteries 160 to PCBA 120. Although soldering may be used inalternative embodiments, one advantage of spring fingers 235 and 236 isthat they allow batteries 160 to be removed from PCBA 120 and holder 150without damaging either of those components, thus allowing for multiplereuses of both. Eliminating solder connections also simplifies andspeeds up assembly and disassembly of monitoring device 100.

In some embodiments, upper housing member 140 may act as a patient eventtrigger. When a patient is wearing physiological monitoring device 100for cardiac rhythm monitoring, it is typically advantageous for thepatient to be able to register with device 100 (for example, log intothe device's memory) any cardiac events perceived by the patient. If thepatient feels what he/she believes to be an episode of heart arrhythmia,for example, the patient may somehow trigger device 100 and thus providea record of the perceived event. In some embodiments, trigger ofperceived events by the patient may initiate transmission of dataassociated with the triggered event. In some embodiments, trigger ofperceived events may simply mark a continuous record with the locationof the triggered event. In some embodiments, both transmission ofassociated data as well as marking of the continuous record may occur.At some later time, the patient's recorded symptom during the perceivedevent could be compared with the patient's actual heart rhythm, recordedby device 100, and this may help determine whether the patient'sperceived events correlate with actual cardiac events. One problem withpatient event triggers in currently available wearable cardiac rhythmmonitoring devices, however, is that a small trigger may be hard to findand/or activate, especially since the monitoring device is typicallyworn under clothing. Additionally, pressing a trigger button may affectthe electronics and/or the electrodes on the device in such a way thatthe recorded heart rhythm signal at that moment is altered simply by themotion caused to the device by the patient triggering. For example,pressing a trigger may jar one or both of the electrodes in such a waythat the recorded heart rhythm signal at that moment appears like anarrhythmia, even if no actual arrhythmia event occurred. Additionally,there is a chance that the trigger may be inadvertently activated, forinstance while sleeping or laying on the monitoring device.

In the embodiment shown in FIGS. 1A and 1B, however, housing 115 issufficiently rigid, and flexible body 110 is sufficiently flexible, thatmotion applied to housing 115 by a patient may rarely or ever cause anaberrant signal to be sensed by the electrodes. In this embodiment, thecentral portion of upper housing member 140 is slightly concave and,when pressed by a patient who is wearing device 100, this centralportion depresses slightly to trigger a trigger input on PCBA 120.Because the entire upper surface of housing 115 acts as the patientevent trigger, combined with the fact that it is slightly concave, itwill generally be quite easy for a patient to find and push down thetrigger, even under clothing. Additionally, the concave nature of thebutton allows it to be recessed which protects it from inadvertentactivations. Thus, the present embodiment may alleviate some of theproblems encountered with patient event triggers on currently availableheart rhythm monitors. These and other aspects of the features shown inFIGS. 1A and 1B will be described in further detail below.

Referring now to the embodiments in FIGS. 2A and 2B, printed circuitboard assembly 120 (or PCBA) may include a top surface 220, a bottomsurface 230, a patient trigger input 210 and spring contacts 235, 236,and 237. Printed circuit board assembly 120 may be used to mechanicallysupport and electrically connect electronic components using conductivepathways, tracks or electrode traces 311, 312. Furthermore, because ofthe sensitive nature of PCBA 120 and the requirement to mechanicallyinterface with rigid housing 115, it is beneficial to have PCBA 120 besubstantially rigid enough to prevent unwanted deflections which mayintroduce noise or artifact into the ECG signal. This is especiallypossible during patient trigger activations when a force is transmittedthrough rigid housing 115 and into PCBA 120. One way to ensure rigidityof the PCBA is in some embodiments, to ensure that the thickness of thePCBA is relatively above a certain value. For example, a thickness of atleast about 0.08 cm is desirable and, more preferably, a thickness of atleast about 0.17 cm is desirable. In this application, PCBA 120 may alsobe referred to as, or substituted with, a printed circuit board (PCB),printed wiring board (PWB), etched wiring board, or printed circuitassembly (PCA). In some embodiments, a wire wrap or point-to-pointconstruction may be used in addition to, or in place of, PCBA 120. PCBA120 may include analog circuits and digital circuits.

Patient trigger input 210 may be configured to relay a signal from apatient trigger, such as upper housing member 140 described above, toPCBA 120. For example, patient trigger input 210 may be a PCB switch orbutton that is responsive to pressure from the patient trigger (forexample, the upper surface of upper housing member portion 140). Invarious embodiments, patient trigger input 210 may be a surface mountedswitch, a tactile switch, an LED illuminated tactile switch, or thelike. In some embodiments, patient trigger input 210 may also activatean indicator, such as an LED. Certain embodiments may involve a remotelylocated trigger such as on a separate device or as a smart phone app.

One important challenge in collecting heart rhythm signals from a humanor animal subject with a small, two-electrode physiological monitoringdevice such as device 100 described herein, is that having only twoelectrodes can sometimes provide a limited perspective when trying todiscriminate between artifact and clinically significant signals. Forexample, when a left-handed patient brushes her teeth while wearing asmall, two-electrode physiological monitoring device on her left chest,the tooth brushing may often introduce motion artifact that causes arecorded signal to appear very similar to Ventricular Tachycardia, aserious heart arrhythmia. Adding additional leads (and, hence, vectors)is the traditional approach toward mitigating this concern, but this istypically done by adding extra wires adhered to the patient's chest invarious locations, such as with a Holter monitor. This approach is notconsistent with a small, wearable, long term monitor such asphysiological monitoring device 100.

An alternate approach to the problem described above is to provide oneor more additional data channels to aid signal discrimination. In someembodiments, for example, device 100 may include a data channel fordetecting patch motion. In certain embodiments, an accelerometer orother suitable device may provide patch motion by simply analyzing thechange in magnitude of a single axis measurement, or alternatively ofthe combination of all three axes. The accelerometer may record devicemotion at a sufficient sampling rate to allow algorithmic comparison ofits frequency spectrum with that of the recorded ECG signal. If there isa match between the motion and recorded signal, it is clear that thedevice recording in that time period is not from a clinical (forexample, cardiac) source, and thus that portion of the signal can beconfidently marked as artifact. This technique may be particularlyuseful in the tooth brushing motion example aforementioned, where therapid frequency of motion as well as the high amplitude artifact issimilar to the heart rate and morphology, respectively, of a potentiallylife-threatening arrhythmia like Ventricular Tachycardia. Other suitabledevices described herein this section and elsewhere in the specificationmay also be utilized to provide motion information.

In some embodiments, using the magnitude of all three axes for such ananalysis would smooth out any sudden changes in values due to a shift inposition rather than a change in activity. In other embodiments, theremay be some advantage in using a specific axis of measurement such asalong the longitudinal axis of the body to focus on a specific type ofartifact introduced by upward and downward movements associated withwalking or running. In a similar vein, the use of a gyroscope inconjunction with the accelerometer may provide further resolution as tothe nature of the motion experienced. While whole body movements may besufficiently analyzed with an accelerometer on its own, specific motionof interest such as rotational motion due to arm movement issufficiently complex that an accelerometer alone might not be able todistinguish.

In addition to detecting motion artifact, an accelerometer tuned to thedynamic range of human physical activities may provide activity levelsof the patient during the recording, which can also enhance accuracy ofalgorithmic true arrhythmia detection. Given the single-lead limitationof device 100, arrhythmias that require observation of less prominentwaves (for example P-wave) in addition to rate changes such asSupraventricular Tachycardia pose challenges to both computerizedalgorithms as well as the trained human eye. This particular arrhythmiais also characterized by the sudden nature of its onset, which may bemore confidently discriminated from a non-pathological Sinus Tachycardiaif a sudden surge in the patient's activity level is detected at thesame time as the increase in heart rate. Broadly speaking, the provisionof activity information to clinical professionals may help themdiscriminate between exercise-induced arrhythmia versus not. As withmotion artifact detection, a single-axis accelerometer measurementoptimized to a particular orientation may aid in more specificallydetermining the activity type such as walking or running. Thisadditional information may help explain symptoms more specifically andthereby affect the subsequent course of therapeutic action.

In certain embodiments, an accelerometer with 3 axes may conferadvantages beyond what magnitude of motions can provide. When thesubject is not rapidly moving, 3-dimensional accelerometer readings mayapproximate the tilt of PCBA 120, and therefore body orientationrelative to its original orientation. The original body orientation canbe assumed to be in either an upright or supine position which isrequired for appropriate positioning and application of the device tothe body. This information may aid in ruling out certain cardiacconditions that manifest as beat-to-beat morphology changes, such ascardiac alternans where periodic amplitude changes are observed, oftenin heart failure cases. Similar beat-to-beat morphology changes areobservable in healthy subjects upon shift in body position due to theshift in heart position relative to the electrode vector, for examplefrom an upright to a slouching position. By design, the single-channeldevice 100 does not have an alternate ECG channel to easily rule outpotential pathological shifts in morphology, however, correlation withshifts in body orientation will help explain these normal changes andavoid unnecessary treatment due to false diagnosis.

In other embodiments, the accelerometer may also be used as a sleepindicator, based on body orientation and movement. When presentingclinical events (for example, pauses), it is diagnostically helpful tobe able to present information in a manner that clearly separates eventsthat occurred during sleep from those during waking hours. In fact,certain algorithms such as for ECG-derived respiratory rate only makesense to run when the patient is in a relatively motionless state andtherefore subtle signal modulation introduced by chest movement due tobreathing is observable. Respiratory rate information is useful as onechannel of information necessary to detect sleep apnea in certainpatient populations.

In certain embodiments, the accelerometer may also be used to detectfree-falls, such as fainting. With an accelerometer, device 100 may beable to mark fainting (syncope) and other free-fall events withoutrelying on patient trigger. In some embodiments, such free-fall eventtriggers may initiate transmission of associated data. In order to allowtimely detection of such critical events, yet considering the batteryand memory limitations of a small, wearable device such as device 100,acquisition of accelerometer readings may be done in bursts, where onlyinteresting information such as a potential free fall is written tomemory at a high sampling rate. An expansion of this event-triggerconcept is to use specific tapping motions on device 100 as a patienttrigger instead of or in conjunction with the button previouslydescribed. The use and detection of multiple types of tapping sequencesmay provide better resolution and accuracy into what exactly the patientwas feeling, instead of relying on the patient to manually record theirsymptom and duration in a trigger log after the fact. An example of suchadded resolution is to indicate the severity of the symptom by thenumber of sequential taps.

Alternatively, in other embodiments, optical sensors may be used todistinguish between device motion and patient body motion. Further, inadditional embodiments, the device may not require a button or trigger.In still more embodiments, suitable devices described herein thissection or elsewhere in the specification may also be used.

Another optional data channel that may be added to physiologicalmonitoring device 100 is a channel for detecting flex and/or bend ofdevice 100. In various embodiments, for example, device 100 may includea strain gauge, piezoelectric sensor or optical sensor to detect motionartifact in device 100 itself and thus help to distinguish betweenmotion artifact and cardiac rhythm data. Yet another optional datachannel for device 100 may be a channel for detecting heart rate. Forexample, a pulse oximeter, microphone or stethoscope may provide heartrate information. Redundant heart rate data may facilitatediscrimination of ECG signals from artifact. This is particularly usefulin cases where arrhythmia such as Supraventricular Tachycardia isinterrupted by artifact, and decisions must be made whether the episodewas actually multiple shorter episodes or one sustained episode. Anotherdata channel may be included for detecting ambient electrical noise. Forexample, device 100 may include an antenna for picking upelectromagnetic interference. Detection of electromagnetic interferencemay facilitate discrimination of electrical noise from real ECG signals.Any of the above-described data channels may be stored to support futurenoise discrimination or applied for immediate determination of clinicalvalidity in real-time.

With reference now to the embodiments of FIGS. 3A and 3B, flexible body110 is shown in greater detail. As illustrated in FIG. 3A, flexible body110 may include wings 130, 131, a thin border 133 (or “rim” or “edge”)around at least part of each wing 130, 131, electrode traces 311, 312,and a hinge portion 132 (or “shoulder”) at or near a junction of eachwing 130, 131 with housing 115. Also shown in FIG. 3A is upper gasket370, which is not considered part of flexible body 110 for thisdescription, but which facilitates attachment of flexible body 110 tohousing 115.

Hinge portions 132 are relatively thin, even more flexible portions offlexible body 110. They allow flexible body 110 to flex freely at thearea where it is joined to housing 115. This flexibility enhancescomfort, since when the patient moves, housing 115 can freely lift offof the patient's skin. Electrode traces 311, 312 are also very thin andflexible, to allow for patient movement without signal distortion.Borders 133 are portions of flexible body 110 that is thinner thanimmediately adjacent portions and that provide for a smooth transitionfrom flexible body 110 to a patient's skin, thus preventing edge-liftand penetration of dirt or debris below flexible body 110.

As shown in greater detail in FIG. 3B, flexible body 110 may includemultiple layers. As mentioned previously, in some embodiments, uppergasket 370 and lower gasket 360 are not considered part of flexible body110 for the purposes of this description but are shown for completenessof description. This distinction is for ease of description only,however, and should not be interpreted to limit the scope of thedescribed embodiments. Flexible body 110 may include a top substratelayer 300, a bottom substrate layer 330, an adhesive layer 340, andflexible electrodes 350. Top and bottom substrate layers 300, 330 may bemade of any suitable, flexible material, such as one or more flexiblepolymers. Suitable flexible polymers can include, but are not limitedto, polyurethane, polyethylene, polyester, polypropylene, nylon, teflonand carbon impregnated vinyl. The material of substrate layers 300, 330may be selected based on desired characteristics. For example, thematerial of substrate layers 300, 330 may be selected for flexibility,resilience, durability, breathability, moisture transpiration, adhesionand/or the like. In one embodiment, for example, top substrate layer 300may be made of polyurethane, and bottom substrate layer 330 may be madeof polyethylene or alternatively polyester. In other embodiments,substrate layers 300, 330 may be made of the same material. In yetanother embodiment, substrate layer 330 may contain a plurality ofperforations in the area over adhesive layer 340 to provide for evenmore breathability and moisture transpiration. In various embodiments,physiological monitoring device 100 may be worn continuously by apatient for as many as 14-21 days or more, without removal during thetime of wear and with device 100 being worn during showering, exercisingand the like. Thus, the material(s) used and the thickness andconfiguration of substrate layers 300, 330 affect the function ofphysiological monitoring device 100. In some embodiments, the materialof substrate layers 300, 330 acts as an electric static discharge (ESD)barrier to prevent arcing.

Typically, top and bottom substrate layers 300, 330 are attached to oneanother via adhesive placed on one or both layers 300, 330. For example,the adhesive or bonding substance between substrate layers 300, 330 maybe an acrylic-based, rubber-based, or silicone-based adhesive. In otheralternative embodiments, flexible body 110 may include more than twolayers of flexible material.

In addition to the choice of material(s), the dimensions—thickness,length and width—of substrate layers 300, 330 may be selected based ondesired characteristics of flexible body 110. For example, in variousembodiments, the thickness of substrate layers 300, 330 may be selectedto give flexible body 110 an overall thickness of between about 0.1 mmto about 1.0 mm. According to various embodiments, flexible body 110 mayalso have a length of between about 7 cm and 15 cm and a width of about3 cm and about 6 cm. Generally, flexible body 110 will have a lengthsufficient to provide a necessary amount of separation betweenelectrodes 350. For example, in one embodiment a distance from thecenter of one electrode 350 to the center of the other electrode 350should be at least about 6.0 cm and more preferably at least about 8.5cm. This separation distance may vary, depending on the application. Insome embodiments, substrate layers 300, 330 may all have the samethickness. Alternatively, the two substrate layers 300, 330 may havedifferent thicknesses.

As mentioned above, hinge portions 132 allow the rigid housing 115 tolift away from the patient while flexible body 110 remains adhered tothe skin. The functionality of hinge portions 132 is critical inallowing the device to remain adhered to the patient throughout variousactivities that may stretch and compress the skin. Furthermore, hingeportions 132 allow for significantly improved comfort while wearing thedevice. Generally, hinge portions 132 will be sufficiently wide enoughto provide adequate lift of rigid housing 115 without creating too largeof a peel force on flexible body 110. For example, in variousembodiments, the width of hinge portion 132 should be at least about0.25 cm and more preferably at least about 0.75 cm.

Additionally, the shape or footprint of flexible body 110 may beselected based on desired characteristics. As seen in FIG. 3A, wings130, 131 and borders 133 may have rounded edges that give flexible body110 an overall “peanut” shape. However, wings 130, 131 can be formed inany number of different shapes such as rectangles, ovals, loops, orstrips. In the embodiment shown in FIGS. 3A and 3B, the footprint topsubstrate layer 300 is larger than the footprint of bottom substratelayer 330, with the extension of top substrate layer 300 forming borders133. Thus, borders 133 are made of the same polyurethane material thattop layer 300 is made of Borders 133 are thinner than an adjacentportion of each wing 130, 131, since they includes only top layer 300.The thinner, highly compliant rim and/or border 133 will likely enhanceadherence of physiologic monitoring device 100 to a patient, as itprovides a transition from an adjacent, slightly thicker portion ofwings 130, 131 to the patient's skin and thus helps prevent the edge ofthe flexible body 110 from peeling up off the skin. Border 133 may alsohelp prevent the collection of dirt and other debris under flexible body110, which may help promote adherence to the skin and also enhance theaesthetics of the flexible body 110. In some embodiments, the border 133may comprise a width (e.g., from an outer edge of the border 133 to aninner edge of the border 133) of at least about 3 mm, 6 mm, 9 mm, 12 mm,or 15 mm. In alternative embodiments, the footprint of substrate layers300, 330 may be the same, thus eliminating borders 133.

While the illustrated embodiments of FIGS. 1A-3B include only two wings130, 131, which extend from housing 115 in approximately oppositedirections (for example, at a 180-degree angle relative to each other),other configurations are possible in alternative embodiments. Forexample, in some embodiments, wings 130, 131 may be arranged in anasymmetrical orientation relative to one another and/or one or moreadditional wings may be included. As long as sufficient electrodespacing is provided to permit physiological signal monitoring, and aslong as wings 130, 131 are configured to provide extended attachment tothe skin, any suitable configuration and number of wings 130, 131 andelectrode traces 311, 312 may be used. The embodiments described abovehave proven to be advantageous for adherence, patient comfort andaccuracy of collected heart rhythm data, but in alternative embodimentsit may be possible to implement alternative configurations.

Adhesive layer 340 is an adhesive that is applied to two portions of thebottom surface of bottom substrate layer 330, each portion correspondingto one of wings 130, 131. Adhesive layer 340 thus does not extend alongthe portion of bottom substrate layer 330 upon which housing 115 ismounted. Adhesive layer 340 may be made of any suitable adhesive,although certain adhesives have been found to be advantageous forproviding long term adhesion to patient skin with relative comfort andlack of skin irritation. For example, in one embodiment, adhesive layer340 is a hydrocolloid adhesive. In another embodiment, the adhesivelayer 340 is comprised of a hydrocolloid adhesive that containsnaturally-derived or synthetic absorbent materials which take upmoisture from the skin during perspiration.

With reference now to FIG. 3B, each of the two portions of adhesivelayer 340 includes a hole, into which one of electrodes 350 fits.Electrodes 350 are made of flexible material to further provide foroverall conformability of flexible body 110. In one embodiment, forexample, flexible electrodes 350 may be made of a hydrogel. Electrodes350 generally provide conformal, non-irritating contact with the skin toprovide enhanced electrical connection with the skin and reduce motionartifact. In some embodiments, hydrogel electrodes 350 may be punchedinto adhesive layer 340, thus forming the holes and filling them withhydrogel electrodes 350. In one alternative embodiment, electrodes 350and adhesive 340 may be replaced with an adhesive layer made of aconductive material, such that the entire adhesive layer on theunderside of each wing 130, 131 acts as an electrode. Such an adhesivelayer may include a hybrid adhesive/conductive substance or adhesivesubstance mixed with conductive elements or particles. For example, inone embodiment, such an adhesive layer may be a hybrid of a hydrogel anda hydrocolloid adhesive. Housing 115 of FIG. 1A also protects theelectronics and power source contained in the housing and/or the PCBA120, enhances the ability of a patient to provide an input related to aperceived cardiac event, and allows for simple manufacturing andreusability of at least some of the contents of housing 115. These andother features of physiological monitoring device 100 are described ingreater detail below.

As discussed above, in some embodiments, adhesive layer 340 may cover aportion of the underside of lower substrate layer 330, such that atleast a portion of the bottom side of flexible body 110 does not includeadhesive layer 340. As seen in FIG. 3A, hinges 132 may be formed in theflexible body 110 as portions of each wing 130, 131 on which adhesivelayer 340 is not applied. Hinge portions 132 are generally located at ornear the junction of flexible body 110 with housing 115, and thusprovide for flexing of device 100 to accommodate patient movement. Insome embodiments, hinge portions 132 may have a width that is less thanthat of adjacent portions of wings 130, 131, thus giving device 100 its“peanut” shape mentioned above. As shown in FIG. 8 , as a subject moves,device 100 flexes along with patient movement. Device flexion may besevere and is likely to occur many times during long term monitoring.Hinge portions 132 may allow for dynamic conformability to the subject,while the rigidity of housing 115 may allow housing 115 to pop up offthe patient's skin during device flexion, thus preventing peeling of thedevice 100 off of the skin at its edge.

Flexible body 110 further includes two electrode traces 311, 312sandwiched between upper substrate layer 300 and lower substrate layer330. Each electrode trace 311, 312 may include an electrode interfaceportion 310 and an electrocardiogram circuit interface portion 313. Asillustrated in the embodiments of FIGS. 3C and 3D, ECG circuit interfaceportions 313 are in physical contact with spring fingers 237 and provideelectrical communication with PCBA 120 when device 100 or zoomed-indevice portion 101 is assembled. Electrode interface portions 310contact hydrogel electrodes 350. Thus, electrode traces 311, 312transmit cardiac rhythm signals (and/or other physiological data invarious embodiments) from electrodes 350 to PCBA 120.

The material and thickness of electrode traces 311, 312 are importantfor providing a desired combination of flexibility, durability andsignal transmission. For example, in one embodiment, electrode traces311, 312 may include a combination of silver (Ag) and silver chloride(AgCl). The silver and silver chloride may be disposed in layers. Forexample, one embodiment of electrode traces 311, 312 may include a toplayer of silver, a middle layer of carbon impregnated vinyl, and abottom (patient-facing) layer of silver chloride. In another embodiment,both top and bottom layers of electrode traces 311, 312 may be made ofsilver chloride. In one embodiment, the top and bottom layers may beapplied to the middle layer in the form of silver ink and silverchloride ink, respectively. In an alternative embodiment, each electrodetrace may include only two layers, such as a top layer of silver and abottom layer of silver chloride. In various embodiments, the material ofa bottom layer of each electrode trace 311, 312, such as AgCl, may beselected to match the chemistry of the hydrogel electrodes 350 andcreate a half-cell with the body of the subject.

The thickness of the electrode traces 311, 312 may be selected tooptimize any of a number of desirable properties. For example, in someembodiments, at least one of the layers of electrode traces 311, 312 canbe of a sufficient thickness to minimize or slow depletion of thematerial from an anode/cathode effect over time. Additionally, thethickness may be selected for a desired flexibility, durability and/orsignal transmission quality.

As mentioned above, in some embodiments, top gasket 370 and bottomgasket 360 may be attached upper substrate 300 and lower substrate 330of flexible body 110. Gaskets 360, 370 may be made of any suitablematerial, such as urethane, which provides a water tight seal betweenthe upper housing member 140 and lower housing member 145 of housing115. In one embodiment, top gasket 370 and/or bottom gasket 360 mayinclude an adhesive surface. FIG. 3E depicts yet another embodimentwhere top gasket 370 includes tabs 371 that protrude away from theprofile of top housing member 140 while still being adhered to uppersubstrate 300. The tabs 371 cover a portion of electrode traces 311, 312and provide a strain relief for the traces at the point of higheststress where the flexible body meets the housing.

FIGS. 4A-4E depict embodiments of adhesive layers 340, which can beincluded as adhesive layers in the embodiments of FIGS. 1-3 and below inFIGS. 5A-8D. Such adhesive layers may be incorporated into any of thephysiological monitoring device embodiments described herein thissection or elsewhere in the specification. In certain embodiments, theadhesive layer 340 may be configured to optimize (e.g., maximize)transpiration of moisture from the surface of the patient's skin beneatha physiological monitoring device such as depicted in FIGS. 1A-B, 3A-3E,and 5A-8D, through the wings of said devices such as described above as130, 131. Promoting transpiration of moisture through the physiologicalmonitoring device 100 (as shown in FIG. 3E and elsewhere) may improveadhesion of the device 100 to the patient's skin by preventing,reducing, and/or inhibiting the collection or pooling of moisturebetween the patient's skin and the bottom of the adhesive layer 340.Collection of moisture between the patient's skin and the bottom of theadhesive layer 340 may prevent, inhibit, and/or interfere with theadhesion of the adhesive layer 340 to the patient's skin, especiallyover long durations. For instance, the presence of excessive moisturemay cause, promote, and/or accelerate the peeling of the edges of theadhesive layer 340 away from the patient's skin. Accordingly, longerterm adhesion may be achieved by promoting the transpiration of moisturethrough the device so that it may be released (e.g., evaporate) into theatmosphere. The management of moisture may be particularly advantageousfor when the patient sweats, such as during exercise or during a hotshower.

In particular embodiments, the adhesive layer 340 may generally comprisea top surface adhered to a bottom surface of the bottom substrate layer330 (such as shown in FIG. 3B and elsewhere) or another support layerand a bottom surface configured to be adhered to the patient's skin. Thetop surface may generally overlap the bottom surface, and/or the top andbottom surfaces of the adhesive layer 340 may define an adhesion area orsurface area that extends in a horizontal plane to a peripheral edge ofthe adhesive layer 340. The adhesive layer 340 may have a verticalthickness extending from the bottom surface to the top surface. Thethickness may be relatively uniform across the adhesion area. In someembodiments, the adhesive layer 340 may comprise a plurality of channels341 connecting the bottom surface of the adhesion layer 340 to the topsurface and/or the peripheral edge of the adhesive layer 340. Thechannels 341 may be formed as hollow voids within the adhesive layer340. The cumulative surface area of the channels 341 where the channels341 interface the skin of the subject may, in some embodiments, beproportional to the rate of moisture transpiration. Larger cumulativesurface areas of void regions may increase the rate of transpiration butmay reduce the amount of adhesive force between the skin of the subjectand the adhesive layer 340. The adhesive layer 340 may or may notcomprise barriers separating the void volumes from the adhesive matrixmaterial (e.g., the hydrocolloid).

In some embodiments, the inclusion of channels 341 within the adhesivelayer 340 may generally make the adhesive layer 340 more conformable tothe surface of the subject (e.g., the skin). For instance the adhesivelayer 340 may better absorb bending strain due to the presence of theplurality of channels 341, which may promote or improve adhesion of thephysiological monitoring devices (such as described herein this sectionor throughout the specification) to the subject, particularly on anon-flat surface and/or on a portion of the body expected to experiencedynamic conformational changes. The plurality of channels 341 can bearranged to promote customized movement or strain of the flexible body110 (as shown in FIG. 3B and elsewhere) in response to particular musclestretches and/or contractions.

FIGS. 4A-4E further display examples of adhesive layers 340 comprisingdifferent arrangements of channels 341. The plurality of channels 341may be generally linear and/or non-linear. In some embodiments, theplurality of channels 341 may comprise vertical channels 341 that extendfrom the top surface to the bottom surface of the adhesive layer 340.FIG. 4A schematically illustrates a top view of a portion of adhesivelayer comprising vertical channels 341. The vertical channels 341 mayextend in a direction substantially normal to the top surface and/or thebottom surface of the adhesive layer 340. The cross-sections of thevertical channels 341 may have generally diamond shapes, as shown inFIG. 4A, circular shapes (e.g., cylindrical channels), oval shapes,rectangular shapes, trapezoidal shapes, pentagonal shapes, hexagonalshapes, other polygonal shapes, or any other suitable shape. In someembodiments, particularly in which vertical channels 341 are closelyspaced, the remaining adhesive layer 340 may take the form of a latticestructure, as shown in FIG. 4A. The shape of the vertical channels 341may affect the mechanical properties of the latticed adhesive layer 340.Diamond-shaped channels 341 may allow preferential expansion and/orcompression in an accordion-like fashion. For example, the adhesivelayer 340 illustrated in FIG. 4A may provide less resistance to tensionand/or compression along axes parallel to those that bisect the angularcorners of the diamond-shaped vertical channels 341 than along axeswhich are parallel to the latticed struts formed from the adhesive layer340. Also, the adhesive layer 340 may provide less resistance to tensionand/or compression along axes parallel to those that bisect largerangles of the vertical channels 341 than axes parallel to those thatbisect smaller angles of the vertical channels.

In some embodiments, the plurality of channels 341 may comprisehorizontal rows or columns of channels 341 that connect the top andbottom surfaces of the adhesive layer 340. The rows or columns may bearranged in a relatively uniformly spaced manner. The rows or columnsmay extend from and/or to the periphery of the adhesive layer 340. Therows or columns may extend across the adhesive layer to another point onthe periphery of the adhesive layer 340 dividing the adhesive layer intothin strips 342. FIG. 4B schematically illustrates an adhesive layer 340comprising column channels 341. In some implementations, an adhesivelayer 340 comprising either rows or columns of channels 341 may beconfigured to be oriented on the subject such that the rows or columnsextend parallel to the height of the subject (e.g., aligned with adirection from the subject's head to the subject's feet). Aligning thechannels 341 entirely or even partially with the height of the subjectmay advantageously promote gravity-facilitated drainage of moisture fromunder the adhesive layer 340 when the subject (e.g., a human subject) isin an upright (e.g., standing) position. The direction of the channel341 can be defined by orthogonal components and the effect of thegravity may depend on the magnitude of the component aligned with theheight. Aligning the channels 341 in a first direction (e.g., alignedwith the height of the subject) may partially relieve tensile and/orcompressive forces along a second direction orthogonal to the firstdirection (e.g., aligned transverse to the height of the subject). Insome embodiments, the channels 341 may be arranged such that thechannels 341 are aligned transverse to a direction expected to undergothe most significant strain (e.g., the channels 341 may be alignedtransverse to a direction of extension/contraction of a muscle overwhich the physiological monitoring device 100 is positioned). Thechannels 341 may absorb some of the strain improving the longevity ofthe adhesive layer 340. The presence of and, particularly, thearrangement of the channels 341 may mechanically improve the resistanceof the adhesive layer 340 to delamination from the skin of the subject,particularly along certain directions, and may promote longer termadhesion of the physiological monitoring device 100 (such as shown inFIG. 3E and elsewhere).

In some embodiments, the plurality of channels 341 may comprise bothrows and columns. The rows and columns may be arranged in a uniformlyspaced manner (e.g., substantially perpendicular to each other) to forma lattice network which divides the adhesive layer 340 into smallislands 343 of adhesive material. The islands 343 may have rectangularconfigurations (e.g., a perpendicular lattice network), diamondconfigurations, trapezoidal configurations, pentagonal configurations,hexagonal configurations, other polygonal configurations, etc. FIGS. 4Cand 4D schematically illustrate examples of an adhesive layer 340comprising lattice networks of channels 341. In various embodiments,there may be a maximum separation distance 344 between the channels 341.In other words, each channel 341 may be separated from another channel341 or from a peripheral edge of the adhesive layer 340 at any pointalong the length of the channel 341 by no more than the maximumseparation distance 344. In some embodiments, the maximum separationdistance 344 may be approximately 1 mm, 2 mm, 3 mm, 4 mm, 5 mm, 6 mm, 7mm, 8 mm, 9 mm, 10 mm, 11 mm, 12 mm, 13 mm, 14 mm, 15 mm, 20 mm, 25 mm,30 mm, or greater than 30 mm. The actual separation distance may beequal to the maximum separation distance 344. In some preferredembodiments, the separation distance may be approximately 8 mm. Theclose spacing of the channels 341 (e.g., within the maximum separationdistance 344) may more efficiently promote the transpiration of moisturefrom beneath the adhesive layer 340 and/or may prevent, inhibit, ordecrease the amount of peeling of the adhesive layer 340 from the skinof the subject.

In some embodiments, the strips 342 and/or islands 343 of the adhesivematerial may be interconnected by a network of thin webbing 345. Thewebbing 345 may comprise thin, flexible strands of material coupling thestrips 342 and/or islands 343 together. In some embodiments, the webbing345 may comprise nylon, cotton, polyester, and/or another suitablematerial. In some embodiments, the webbing 345 may extend through thestrips 342 and/or islands 343, as schematically illustrated in FIG. 4B.For instance, in some embodiments, the strips 342 and/or islands 343 maybe formed around the strands of the webbing 345 such that the strandsextend through an interior volume of the strip 342 and/or island 343. Insome embodiments, the network of webbing 345 may comprise a generallyperpendicular network of columns and rows of strands as shown in FIGS.4C and 4D. In some embodiments, the network of webbing 345 may beoriented in substantially the same manner as the rows and columns ofchannels 341 as shown in FIG. 4C, where rows of strands intersperse rowsof channels 341 and columns of strands intersperse columns of channels341. In some embodiments, the network of webbing 345 may be oriented ina different manner such as shown in FIG. 4D, where the rows and columnsof webbing 345 strands are approximately 45 degrees offset from the rowsand columns of channels 341. The webbing 345 may extend diagonallythrough the islands 343 and strands of webbing 345 may cross each otherwithin the channels 341.

In some embodiments, the channels 341 may be arranged in a radialpattern (e.g., a linear spoke pattern). In some embodiments, thechannels 341 may be non-linear (e.g., a coaxial arrangement ofring-shaped channels 341). For example, the channels 341 may be radiallyarranged in the horizontal plane in a spiraling fashion, asschematically illustrated in FIG. 4E. The channels 341 may meet at acentral point 346. In some embodiments, the central point 346 may be asolid piece of the adhesive layer 340. In some embodiments, the centralpoint 346 may be a void space, as shown in FIG. 4E. The void space maybe substantially circular. In some embodiments, the void space maycomprise at least about 5%, 10%, 15%, 20%, 25%, or 30% of the totalsurface area of the adhesive layer 340.

In some embodiments, the strips 342 and/or islands 343 of adhesivematerial may be affixed to a thin backing layer. For instance, in someembodiments the strips 342 and/or islands 343 may be formed directly ona bottom surface of the bottom substrate layer 330. In some embodiments,the adhesive layer 340 may be formed on a removable backing layer whichis removed from the adhesive layer 340 after it is transferred to thebottom substrate layer 330 of the flexible body 110. In someembodiments, the adhesive layer 340 may be formed free of any backinglayer (e.g., formed around the webbing 345). In some embodiments, thechannels 341 may be formed during fabrication of the adhesive layer 340.For instance, the adhesive matrix of the adhesive layer 340 may beformed around a die imparting the shape of the channels 341. In someembodiments, the channels 341 may be formed after fabrication of theadhesive layer 340. For instance, after fabrication the adhesive layer340 may be perforated or vertical channels 341 may be punched throughthe adhesive layer 340. In some embodiments, tubes (e.g., capillarytubes) may be inserted into and through the adhesive layer 340 to formvertical channels 341. In some embodiments, horizontal strips ofadhesive layer may be removed (e.g., by cutting) leaving behind strips342 and/or islands 343 of the adhesive material. In some embodiments,the adhesive matrix of the adhesive layer 340 may be formed on a backinglayer or substrate, which may optionally be removed from the adhesivelayer 340 prior to adhering the adhesive layer 340 to the bottomsubstrate layer 330 (such as shown in FIG. 3B and elsewhere). In someembodiments, the adhesive layer 340 may be fabricated around strands ofa network of woven or non-woven webbing 345 as described elsewhereherein. In instances where the adhesive layer is fabricated aroundstrands of non-woven webbing, the channels may manifest as random voids(which may have any suitable shape, such as an ellipsoid) dispersedthrough the adhesive. Where the voids and/or pockets connect, channelsare formed but even where they do not connect directly, their presencemay enable improvement of air flow through the adhesive. With a lesssolid adhesive layer, this approach may improve conformability to theskin. In some embodiments, a network of webbing 345 may be coupled tothe adhesive layer 340 (e.g., pressed into) after the adhesive layer hasbeen fabricated. A network of webbing 345 may be useful for helping toremove the adhesive layer 340 form a die or backing layer and/or forpositioning the adhesive layer 340 over the bottom substrate layer 330of the flexible body 110. In certain embodiments, the adhesive layer 340may include channels for transpiration. Such channels may or may nothave continuous walls. In certain embodiments, the channels may bevertical, orthogonal, or be oriented at any suitable angle.

In some embodiments, the adhesive layer 340 may comprise moisturewicking materials (e.g., water adsorbing materials) and/or may becoupled to a layer of moisture wicking materials. The moisture wickingmaterials may comprise a matrix of moisture wicking fibers. The moisturewicking materials may comprise wool, nylon, polyethylene terephthalate(PET), polytetrafluoroethylene (PTFE), expanded PTFE (ePTFE),thermoplastic elastomers (TPE), and/or any other suitablewater-absorbent material. In some embodiments, the moisture wickingmaterials may be hydrophobic and/or hydrophilic, such that the core canretain the water, move it outward/upward and the outer sheath of thefiber can insulate the surrounding adhesive from moisture. The moisturewicking material may be formed as a layer above the top surface of theadhesive layer 340 (e.g., between the adhesive layer 340 and the bottomsubstrate layer 330) or used as capillary tubes. The moisture wickingmaterial may be used to partially or entirely fill or line one or moreof the plurality of channels 341. In some implementations, the inclusionof moisture wicking materials may facilitate drawing moisture from thesurface of the subject through the channels 341 and/or into the adhesivelayer 340 and/or upper substrate layers, such as through a moisturevapor permeable layer. In certain embodiments, the moisture may be movedout to the uppermost surface and optionally evaporated through amoisture vapor permeable layer, and/or to the outer edges of theadhesive for evaporation. The inclusion of moisture wicking materialsmay allow for the storage of moisture within the adhesive layer 340 awayfrom the interface between the bottom of the adhesive layer 340 and theskin of the subject where the moisture is likely to promote delaminationof the adhesive layer 340. The storage of moisture within the adhesivelayer 340 or other layers of the physiological monitoring device 100 maybe advantageous when the moisture from the surface of the subject cannotbe transpired through the device 100 as quickly as it is generated,preventing or inhibiting the buildup of moisture between the bottomsurface of the adhesive layer 340 and the skin. In some embodiments thewicking and/or fibers present in the materials may be oriented such thatmoisture is pulled outward radially from the adhesive. At outer areas ofthe adhesive or where perforations are present, a moisture sink may becreated which maximizes surface area of those fibers, allowing forevaporation of the moisture that accumulates from within.

The peripheral edge of the adhesive layer 340 may promote undesiredadhesion of materials to the periphery of the adhesive layer 340.Particularly in examples comprising a border 133, portions of theflexible body 110 may become adhered to the peripheral edge of theadhesive layer 340. For instance, the bottom surface of the topsubstrate layer 300 forming the border 133 may become adhered to theperipheral edge of the adhesive layer 340. Adhesion of substrate layersof the flexible body 110 to the peripheral edge of the adhesive layer340 may deform the flexible body 110 from its intended configurationand/or may interfere with the proper mechanics and distribution ofstress throughout the flexible body 110 which could inhibit or decreasethe duration of long-term adhesion between the device 100 and the skin.Additionally or alternatively, dirt, debris, or adjacent portions ofskin may become adhered to the peripheral edge of the adhesive layer 340which may also interfere with long-term adhesion. Adhesion of foreignmaterial to the peripheral edge of the adhesive layer 340 may promote orlead to loss of adhesion of material between the skin of the subject andthe bottom surface of the adhesive layer 340. Delamination of theadhesive layer 340 may tend to initiate at the edge of the adhesivelayer 340. If the edge begins to delaminate from the skin, the border133 or other materials which are adhered to the peripheral edge maybecome tucked under the adhesive layer 340 between the bottom surfaceand the skin. For instance, the border 133 may begin to fold under theadhesive layer 340. The wedging of materials between the bottom surfaceof the adhesive layer 340 and the skin of the subject may apply a stressto the adhesive layer 340 and/or deform the adhesive layer 340 which maylead to further delamination, such that peeling may begin to nucleatefrom the peripheral edge. Adhesion between the bottom surface of theadhesive layer 340 and the external material may continue to draw thematerial in under the adhesive layer 340, creating an “inchworm effect,”particularly where the material experiences a stronger adhesion to theadhesive layer 340 than the skin of the subject experiences relative tothe adhesive layer 340.

In some embodiments, adhesion to the peripheral edge of the adhesivelayer 340 may be prevented or inhibited by lining the peripheral edge ofthe adhesive layer 340 with a non-adhesive material in the form of ablocking liner. In certain examples, no adhesive may be applied to theperiphery such that a blocking liner may not be used to prevent orinhibit adhesion to the peripheral edge. Where no adhesive is used atthe periphery, adhesive may be printed to a carrier film, but not to theperiphery. In some embodiments, the non-adhesive material may comprise asilicone (e.g., polydimethylsiloxane (PDMS)) and/or any other suitablematerial. The non-adhesive lining may outline the entire periphery ofthe adhesive layer 340 or may outline continuous and/or discontinuousportions of the periphery. The non-adhesive lining may comprise anannular (e.g., ring-shaped) configuration. An inner diameter of thenon-adhesive lining may be generally equal to an outer diameter of theadhesive layer 340. The non-adhesive liner may be generally flexible orelastic such that it may conform to the peripheral edge of the adhesivelayer 340 and/or may experience dynamic strain as the subject moveswithout delaminating from the adhesive layer 340. The non-adhesivelining may extend from the top of the peripheral edge to the bottom ofthe peripheral edge or may extend along a portion of the thickness(e.g., a top portion, a bottom portion, and/or an intermediate portion).The non-adhesive lining may comprise a width extending from theperipheral edge of the adhesive layer 340 to an outer edge of thelining. The width may be no greater than approximately 0.5 mm, 1 mm, 2mm, 3 mm, 4 mm, or 5 mm. In some embodiments, the inner diameter of thenon-adhesive liner may comprise an adhesive surface, which mayfacilitate the adhesion of the non-adhesive liner to the peripheral edgeof the adhesive layer 340. In some embodiments, the bottom surface ofthe non-adhesive lining may be non-adhesive creating a buffer betweenthe bottom surface of the adhesive layer 340 and the outer diameter ofthe non-adhesive lining. In some embodiments, the bottom surface of thenon-adhesive lining may be adhesive and configured to adhere to the skinof the subject. The non-adhesive liner may prevent or inhibit theadhesion of any portion of the flexible body 110, any other materials,or adjacent portions of skin form adhering to the peripheral edge of theadhesive layer 340 and/or may prevent or inhibit materials frominserting themselves between the bottom surface of the adhesive layer340 and the skin of the subject. The non-adhesive liner may promote orincrease the duration of long-term adhesion of the adhesive layer 340 tothe skin of the subject.

In some embodiments, a peripheral area of the adhesive layer 340 maycomprise a tapered thickness. The thickness of the adhesive layer 340may decrease from a central location radially outward toward theperipheral edge of the adhesive layer 340, and/or vice versa. In someembodiments, the central location may be a generally central point ofthe adhesive layer 340 such that the width is variable across an entireradius of the adhesive layer 340. In some embodiments, a central regionof the adhesive layer 340 may comprise a uniform thickness and aperipheral annular region may comprise a tapered thickness, and/or viceversa. In some embodiments, particularly in embodiments in which theadhesive layer 340 comprises a generally circular surface area, thethickness of the adhesive layer 340 may be uniform in a circumferentialdirection or at points positioned equal distances from the peripheraledge. In some embodiments, at least the outer most 1 mm, 2 mm, 3 mm, 4mm, 5 mm, 6 mm, 7 mm, 8 mm, 9 mm, or 10 mm of the adhesive layer 340 maycomprise a tapering thickness. A more gradual taper may provide for moreadvantageous mechanics and distribute stresses through the adhesivelayer 340 more uniformly. The thickness of the peripheral edge of theadhesive layer 340 may be no greater than approximately 5%, 10%, 15%,20%, 25%, 30%, 40%, or 50% of a maximal thickness of the adhesive layer340 (e.g., at a central portion). In some embodiments, the thickness maytaper down to a generally pointed edge of negligible thickness. Thereduced thickness of the peripheral edge may prevent or prohibitadhesion of the flexible body 110, any other materials, or adjacentportions of skin form adhering to the peripheral edge of the adhesivelayer 340 and/or may prevent or inhibit materials from insertingthemselves between the bottom surface of the adhesive layer 340 and theskin of the subject. The tapered peripheral edge may promote or increasethe duration of long-term adhesion of the adhesive layer 340 to the skinof the subject.

FIGS. 5A-5H schematically illustrate another embodiment of aphysiological monitoring device 200, similar to the physiologicalmonitoring devices depicted in FIGS. 1A-1B and in additional figureslater in the specification, such as FIGS. 6A-6H. FIG. 5A schematicallydepicts a bottom view the physiological monitoring device 200 includingthe horizontal disposition of various constituent layers. Thephysiological monitoring device 200 may comprise wings 232, 231 whichare each asymmetrical or symmetrical about a longitudinal axis extendingbetween the electrodes 350. One of the wings 231, 232 may comprise abody which is disproportionately distributed above the longitudinal axisand the other wing 231 may comprise a body which is disproportionatelydistributed below the longitudinal axis. The wings 231, 232 may make theflexible body asymmetric about a transverse axis, perpendicular to thelongitudinal axis and extending through the housing 215, also includingpatient trigger 216. In certain embodiments, the patient trigger mayencompass about: 10 to 30% of the total top area, such as about 20% ofthe top area or about 23% such as about 22.8% of the total top area. Incertain embodiments, the patient trigger may encompass more than about20%, more than about 30%, more than about 40%, more than about 50%, ormore than about 75%. In certain examples, the patient trigger mayencompass the entire top surface of the housing. The wings 231, 232 maycomprise identical shapes which are reversed or flipped about both thelongitudinal axis and the transverse axis as shown in FIG. 5A. Theconfiguration of the flexible body may be particularly suitable forpositioning the electrodes in a diagonal arrangement with respect to theheight of a subject (e.g., FIGS. 9B-9E).

In various embodiments, such as those shown in FIGS. 3A-3E, FIGS. 5A-5H,and any other embodiments described herein, the one or more of thesubstrate or support layers supporting the adhesive layer 340 and theelectrodes 350 may comprise perforations or apertures 332 disposedthrough the thickness of one or more layers. The apertures 332 mayprovide breathability through one or more layers and may promotetranspiration of moisture from below the adhesive layer 340 through thelayer or layers comprising the apertures 332. The shape and/orarrangement of the apertures 332 may affect the mechanical properties ofthe latticed adhesive layer 340. The apertures 332 may provide a degreeof compliance or conformability to a relatively rigid layer whichprovides structural support to the flexible body 110, 310. For instance,the apertures 332 may promote bendability of the thin layer. In someembodiments, the apertures 332 may be circular in shape as shown in FIG.5A. In some embodiments, the apertures may be diamond-shaped similar tothe vertical channels 341 shown in FIG. 4 . In embodiments, theapertures 332 may be rectangular, square, oval, trapezoidal, pentagonal,hexagonal, polygonal, or any other suitable shape as well. Like thevertical channels 341 in the adhesive layer 340, the apertures 332 maycreate a lattice structure within at least a region of the perforatedlayer, particularly where apertures 332 are positioned close together.The perforated layer may provide anisotropic resistance to tensionand/or compression along various axes within the horizontal plane of theperforated layer in the same manner as described elsewhere herein withrespect to the vertical channels 341.

In some embodiments, the wings 130, 131 may comprise structuralreinforcement members (not shown) along peripheral edges of the wings130, 131. The structural support members may comprise thin wire-likeconfigurations. The structural reinforcement members may be disposed inor in between any layers of the wings 130, 131, such as the topsubstrate layer 300 or the bottom substrate layer 330. In someembodiments, the structural reinforcement members may be disposed in theborders 133 outside and around the adhesive layers 340. The structuralreinforcement members may maintain or preserve the general shape (e.g.,outer outline) of the wings 130, 131 even if the adhesive layer 340begins to peel, deteriorate, and/or break down along the edges. Thestructural support members may comprise a relatively stiff metal orplastic. In some embodiments, the structural support member may comprisea shape memory material (e.g., nitinol). The shape memory properties ofthe shape memory structural support member may resist permanentdeformation of the wings 130, 131 and may help prevent, for example,wrinkling of the wings and/or the border 133 tucking under the adhesivelayer 340.

In some embodiments, the support layer may comprise at least twooverlapping layers of material (e.g., top substrate layer 300 and bottomsubstrate layer 330). In some embodiments, the bottom most substratelayer (e.g., bottom substrate layer 330) and/or the top most substratelayer (e.g. top substrate layer 300) of the flexible body 110 maycomprise more than one layer. The various layers may comprisepolyethylene terephthalate (PET) and/or polyurethane (PU). In variousembodiments, layers comprising PET may provide structural support to theflexible body. PET may be the most rigid or stiff material presentthroughout the layers of the flexible body 110. The layer providingstructural support may also provide resistance to wrinkling of adjacentmore wrinkle-prone (e.g., less rigid) layers. In various embodiments,layers comprising polyurethane may provide a conformable and/orbreathable barrier to the flexible body 110, 310. Polyurethane may bethe least rigid material or at least not the most rigid material presentthroughout the layers of the flexible body 110. The polyurethane maygenerally create a seal against water preventing water from enteringthrough the ambient environment and penetrating between the adhesivelayer 340 and the skin of the subject. The barrier layer may beparticularly advantageous for allowing the subject to shower. Providinga shower-compatible physiological monitoring device may improve usercompliance and/or promote or increase the duration of long-term wear.The polyurethane layer may be generally breathable allowingtranspiration to occur through the polyurethane layer, particularlywhere the polyurethane layer is relatively thin. In some embodiments, aperforated PET layer may be positioned between the adhesive layer 340and the polyurethane layer. In embodiments, a polyurethane layer may bepositioned between the adhesive layer 340 and a perforated PET layer. Insome embodiments, the bottom most substrate layer 330 may be integratedwith the adhesive layers, for example in a spun polyurethane thatenables the adhesive to be formed around the lattice or mesh structureprovided by the substrate.

FIGS. 5B-5G schematically depict bottom views of various componentlayers of the embodiment shown in FIG. 5A and include examples ofnon-limiting dimensions (in mm) of the embodiment. All of the variouslayers forming the wings 231, 232 may comprise overlapping holesconfigured to receive electrodes 350 as described elsewhere herein. FIG.5B illustrates a support layer 202 (e.g., polyurethane) forming the mainstructure of the flexible body. FIG. 5C illustrates a close-up of theinset A depicted in FIG. 5B. FIG. 5D illustrates an additional layerconfigured to form a “butterfly flap” 203 that supports the extension ofadhesive 240, as shown in FIG. 5G, which may serve to limit opportunityfor the adhesive to fold back and stick on itself during application.The butterfly flap layer 203 may extend between hinge lines 134. FIG. 5Eillustrates perforated layers 204 (e.g., perforated PET layers)comprising apertures 332 for providing structural support to the wings231, 232 while permitting moisture transmission. The perforated layers204 may not extend continuously between the wings 231, 232 as shown.FIG. 5F illustrates a close-up view of the inset A depicted in FIG. 5E.FIG. 5G depicts two adhesive layers 240. As shown by a comparison of thevarious layers, the perforated layer 204 may not extend the entirelength of the adhesive layer 240 along the longitudinal axis. Theadhesive layer 240 may extend inward toward the housing 315 beyond thehinge line 134 forming flaps 249 which are supported on the top surfaceby butterfly flap layer 203 and adhered on the bottom surface to skin ofthe subject but which are not adhered to the overlying hinge portion ofthe support layer 202. In certain embodiments, this feature (as shown inFIG. 5B), where the hinge portion 1001 of support layer 202 is anchoredto the subject's skin by both the proximal portion of adhesive 240 andthe distal portion of adhesive 240, may distribute stresses applied uponthe adhesive during wear and minimize peel forces that could more easilyweaken the adhesive bond to skin. FIG. 5H depicts a perspective view ofthe physiological monitoring device 200.

In various embodiments, the adhesive layer (e.g., adhesive layer 340,240, or any other adhesive layer described herein) may be replaceable.Replacing the adhesive layer 340 may prolong the duration of wear of thephysiological monitoring device 100 as a fresh adhesive layer 340 maysupplant an adhesive layer 340 which is beginning to or has lost asubstantial ability to adhere the device 100 to the skin of the subject.To replace an adhesive layer 340, the top surface of the adhesive layer340 may be separated from the bottom surface of the substrate layers ofthe flexible body 110 (e.g., the bottom surface of the bottom substratelayer 330). The physiological monitoring device 100 may be removed fromthe body of the subject and then the adhesive layer 340 separated fromthe flexible body 110. The adhesive layer 340 may be easiest to removeby peeling the adhesive layer 340 from the flexible body 110 beginningat an inside corner of the adhesive layer 340 (e.g., a corner closest tothe housing 115. A specialized removal device may be provided forfacilitating the removal of the adhesive layer 340. For instance, theremoval device may comprise a thin flat blade configured to be insertedbetween the adhesive layer 340 and the flexible body 110. The removaldevice may comprise a handle extending from the blade. The handle mayextend from the blade at an angle such that the blade may be positionedparallel to the flexible body which may be supported on a flat surfaceand the handle may be positioned and held above the flat surface. Forexample, the removal tool may be used to separate a corner of theadhesive layer 340 from the flexible body 110 and then the corner of theadhesive layer 340 may be used to pull or peel the remainder of theadhesive layer 340 from the flexible body 110. The removal tool or aseparate removal tool may comprise a means for grasping the adhesivelayer 340 after it has been partially separated from the substratelayers of the flexible body 110 such that the removal tool may be usedto pull or peel the adhesive layer 340 from the substrate layers of theflexible body 110. The replacement adhesive layer 340 may be applied tothe flexible body 110 in the same or similar manner as when the originaladhesive layer 340 is applied to the substrate layers of the flexiblebody 110 during manufacture or assembly of the physiological monitoringdevice 100. For example, the adhesive layer 340 may be formed on abacking layer on the bottom surface of the adhesive layer 340, which canbe removed after the top surface of the adhesive layer is adhered to theflexible body 110. In some embodiments, the replacement adhesive layermay be applied to the flexible body 110 through the use of a template ortool to enable easy and accurate positioning relative to the features onflexible body 110.

In some embodiments, the adhesive layer 340 may be comprised of multiplelayers. In certain examples, if experiencing adhesion failure or forother suitable reasons, the user may remove the physiological monitoringdevice 100, and remove the bottom-most layer of 340 that was in directcontact with the skin. This removed layer may be the entire surface of340, exposing a fresh adhesive layer of 340 below, or it might be anannular area of 340, exposing a fresh layer in only one portion of theadhesive, or some other smaller area that is less than the entire area.In certain embodiments, the layer of “used” adhesive may take the shapeof a pattern distributed across the surface of adhesive 340, resultingin a distributed mix of fresh adhesive and “used” adhesive across itssurface. Similar to replacement of the adhesive, refreshing the adhesivethrough removal of some or all of the most recent skin-contacting layermay have the effect of extending wear duration. The multiple layers of340 in such an embodiment may be constructed through a combination ofadhesive and release liner, where the release liner may be siliconizedfor releasability on the top surface but adhered more permanently on itsbottom surface or vice-versa. The siliconization may be tuned to allowfor intentional layer removal, without causing undue challenges inmaintaining adhesion on the body. Additionally, in certain examples,adhesive layer removal may be enabled through the use of pull tabs builtinto the layers. Further, removal may also be enabled through a toolthat adheres more strongly to the “used” adhesive than the release lineris adhered to the layer below it. In embodiments, the adhesive may beintegrated within a lattice or mesh substrate, enabling separation fromother layers of adhesive without losing integrity. In some embodiments,the physiological monitoring device 100 may have an annular ring ofadhesive exposed without removal from the user's skin. An inner shape ofadhesive on each wing may remain adhered while an annular ring wasremoved, exposing fresh adhesive and enabling extended wear. Adhesionfailure often begins at the outermost edges of the adhesive, thereforethis approach of refreshing only an annular ring on the outer layer mayhelp extend wear duration while minimizing interruption of datacollection and also increasing likelihood that the user continues towear the device.

In some embodiments, a pull string (not shown) may be sandwiched betweenthe adhesive layer 340 and the bottom substrate layer 330, embedded inthe adhesive layer 340, or partially embedded in the adhesive layer 340and partially sandwiched between the adhesive layer 340 and the bottomsubstrate layer 330. The pull string may have a free tail end at aproximal of the pull string extending beyond a peripheral edge of theadhesive layer 340. The pull string may extend across a surface area ofthe adhesive layer 340 according to a particular pattern. In someembodiments, the pull string may closely follow or trace the peripheraledge of the adhesive layer 340. In some embodiments, the pull string mayclosely follow an outer diameter of the electrode(s) 350. In someembodiments, the pull string may form a substantially closed circuitaround a surface area of the adhesive layer 340. For instance, a distaltail end may be positioned in close proximity to the proximal free tailend. The distal tail end may freely extend beyond the peripheral edge ofthe adhesive layer 340 as does the proximal free tail end or it may bepositioned within the surface area of the adhesive layer 340. The pullstring may be configured to help remove the removable adhesive layerfrom substrate layer 330 or from another layer within adhesive layer340. Pulling the free tail end of the pull string (e.g., pulling thefree tail end of the pull string across a bottom surface of the adhesivelayer 340) may cause the pull string to cut through the adhesive layer340 and/or separate (e.g., lift off) the adhesive layer 340 or portionsthereof from the substrate layers of the flexible body 110. In someembodiments, the pull string may remove a peripheral border area (e.g.,an annular area) of the adhesive layer 340 from an inner central portionof the adhesive layer 340. The border area and/or other portions of theadhesive layer 340 may be lifted off the bottom substrate layer 330 orother layers within adhesive layer 340. Forming a division betweendifferent portions of the adhesive layer 340 may facilitate removal ofthe portions from the bottom substrate layer 330. The new severed edgescreated in the adhesive layer 340 by the pull string may providestarting locations for peeling the adhesive layer 340 from the bottomsubstrate layer 330. These edges may be easier to separate from thenatural or original peripheral edges of the adhesive layer 340,particularly where the natural edges are flush with the edges of thebottom substrate layer 330. It may be easier to lift the severed edge ofthe adhesive layer off of an underlying surface such as the bottomsubstrate layer 330 than to separate two thin edges from each other at aperipheral edge of the flexible body 110. In some embodiments, pullingthe pull string may at least partially lift the severed edge of theadhesive layer 340 off of the bottom surface of the bottom substratelayer 330 making subsequent peeling of the adhesive layer 340 easier. Insome embodiments, the adhesive layer 340 may be naturally segmented orsegmentable along paths not formed by a pull string. For instance, theadhesive layer 340 may be fabricated to be particularly frangible alonga similar outline as the pull string, such as by disposing a path ofperforations across the surface area of the adhesive layer 340. The pullstring may be used in combination with other removal methods and/ortools disclosed elsewhere herein.

In some embodiments, the adhesive layer 340 may extend entirely to theedge or border of the substrate layers (e.g., including top substratelayer 300) such that the top surface of the adhesive layer 340 isadhered to the bottom surface of the border 133 as well as the bottomsurface of the bottom substrate layer 330. In some embodiments, theflexible body 110 may not comprise a border 133 and the adhesive layermay extend to the edge of the bottom substrate layer 330. Embodimentsthat comprise replaceable adhesive layer 340 may be particularlysuitable for adhesive layers 340 that extend to the outer edge or borderof the flexible body 110.

FIGS. 8A-8J illustrate embodiments of a physiological monitoring device400. In some embodiments, the physiological monitoring device 400 maycomprise a housing 415 that is connected to electrode traces 411, 412 asshown in FIGS. 8A and 8B. FIG. 8A shows a side view of the housing 415and traces 411, 412 and FIG. 8B shows a top view of the housing 415 andthe traces 411, 412. The traces 411, 412 may extend from the sidesand/or from the bottom of the housing 415. The traces 411, 412 may befixedly coupled to electrodes 350 at ends opposite the housing 415. Toassemble the physiological monitoring device 400 the housing 415 andtraces 411, 412 may be coupled (e.g., adhered) to a bottom surface of aflexible body 410, as shown in FIG. 8C. The flexible body 410 may be asingle unit of material having a generally continuous flat surface. Theoutline or shape of the flexible body 410 may be the same as otherflexible bodies described herein, maybe generally be round as shown inFIGS. 8C and 8D, or may be any other suitable shape. In someembodiments, the flexible body 410 may comprise apertures for receivingthe electrodes 350. In some embodiments, the electrodes may be builtinto the flexible body 410 (e.g., the electrodes may be disposable). Theflexible body 410 may comprise one or more constituent layers asdescribed elsewhere herein, inclusive of adhesive and border layers. Theconstituent layers may extend continuously across the surface area ofthe flexible body 410 or may be proportioned across discrete sub-areas.The continuous flexible body 410 may be monolithic and continuous,covering the housing 415 and traces 411, 412. In certain embodiments,the flexible body 410 may be cut to allow relief for the housing 415,while covering traces 411 and 412. In embodiments, as shown in FIG. 8C,the continuous flexible body 410 may be cut along a path around afloating portion 420 or butterfly flap portion of the flexible body 410which surrounds the rigid body and/or housing 415 and at least a portionof length of the traces 411, 412 extending from the rigid body and/orhousing 415, but excluding the electrodes. The flexible body 410 may beprovided in a pre-cut configuration prior to coupling the housing 415.In some embodiments, the flexible body 410 may comprise perforations orother frangible features which makes the floating portion 420 readilyseparable from the remainder of the flexible body 410. In someembodiments, the pre-cut areas of flexible body 410 may include a hingedportion that supports the trace as it lifts off the skin. The bottomsurface of the floating portion 420 may be free of adhesive such thatthe floating portion 420 is free to lift off of the skin of the subjectas shown in FIG. 8D and as described elsewhere herein. In particularembodiments, the bottom surface of the distal ends of traces 411, 412,prior to the hinge point, may be coated in adhesive to better secure theelectrodes to the skin.

In some embodiments, a housing 415 may include sensing electrodes 350,as shown in FIGS. 8E (profile) and 8F (top view). A flexible adhesivebody 410 may be placed over top of the housing 415, as shown in FIG. 8G.In some embodiments, the housing 415 may include electrical connections1003 on the exterior surface that enable electrical coupling to tracesintegrated into flexible body 410. Such an arrangement may allow thetraces and electrodes to be disposable and replaced with ease. Couplingbetween trace and housing may be enabled by conductive adhesive,conductive glue, conductive gel, or other suitable conductive material.In some embodiments, a top protective layer (not shown) may be providedover the traces 411, 412 and optionally over the rigid body 410 afterthey are coupled to the flexible body 410. The top protective layer maybe coupled (e.g., adhered) to the flexible body 410. The top protectivelayer may be coupled to the flexible body prior to cutting the floatingsection flexible body 410 so that overlapping cuts are imposed on boththe flexible body 410 and the top protective layer. In some embodiments,the top protective layer may be provided in a pre-cut form.

The flexible body 410 of the physiological monitoring device 400 may bereplaceable. The flexible body 410 may be removed from the housing 415and electrode traces 411, 412 and a replacement flexible body 410 may bereapplied in the same manner as the original was assembled. In certainembodiments discussed herein, the flexible body 410 may include theelectrode traces 411, 412 and flexible body 410 may be removed from thehousing 415 to be replaced by another in the same location. Thisembodiment of the physiological monitoring device 400 may provide aconvenient method for replacing the adhesive layers of the physiologicalmonitoring device 400 after the adhesive layers have begun to wearand/or peel, allowing for a longer duration of use of the device 400.

Physiological Monitoring Device

FIGS. 6A-6H depict an embodiment of a physiological monitoring device700, similar to the physiological monitoring devices depicted in FIGS.1A-5H. FIG. 6A depicts a perspective view of the physiologicalmonitoring device. As in FIG. 5A, the physiological monitoring device700 may comprise wings 730, 731 which are each asymmetrical about alongitudinal axis approximately extending between the electrodeinterface portions 702 which overlie the electrodes positioned on theunderside of the wings. Electrode traces 704, may extend from thehousing to the electrodes, to provide electrical communication betweenthe electrode and the central housing. As in FIG. 5A, above, one of thewings 730 may comprise a body which is disproportionately distributedabove the longitudinal axis and the other wing 731 may comprise a bodywhich is disproportionately distributed below the longitudinal axis.Therefore, the wings 730, 731, may make the flexible body asymmetricabout a transverse axis, perpendicular to the longitudinal axis andextending through the housing 706, which may include patient trigger707, similar to the other patient triggers disclosed herein this sectionor elsewhere in the specification. As described elsewhere herein, incertain embodiments, the patient trigger may encompass about: 10 to 30%of the total top area, such as about 20% of the top area or about 23%such as about 22.8% of the total top area. In certain embodiments, thepatient trigger may encompass more than about 20%, more than about 30%,more than about 40%, more than about 50%, or more than about 75%. Incertain examples, the patient trigger may encompass the entire topsurface of the housing. The wings 730, 731 may comprise identical shapeswhich are reversed or flipped about both the longitudinal axis and thetransverse axis as shown in FIGS. 6A-6C. In some embodiments, the wingsmay be asymmetrical in size and shape, for example the upper wing 730may be larger than the lower wing 731 or vice-versa. The shapes of thewings 730, 731 may differ such that the relative shape of upper wing730, differs from the relative shape of lower wing 731. In certainexamples, the upper wing 730 may be under greater tension than the lowerwing 731 or vice-versa, therefore different sizes and shapes between thetwo wings may aid in addressing unique force vectors during use of thephysiological monitoring device. The configuration of the wings may beparticularly suitable for positioning the electrodes in a diagonalarrangement with respect to the height of a subject, thereforepotentially reducing peel off due to gravity. One of skill in the artwill understand that the orientation of the wings may altered, such thatthe wings are mirrored, rather than being distributed disproportionatelyabove or below a longitudinal axis. Further, those of skill in the artwill understand that the shape of such wings, as described herein, mayvary from the generally rounded shapes depicted in FIGS. 5-6 . Forexample, the wings may be angular, such as a square shape, rectangularshape, triangular shape, pentagonal shape, or any suitable polygonalshape. These polygonal shapes may have rounded corners to reducelikelihood of peeling from the corner. A liner 708, such as depictedelsewhere herein may be used to cover and protect any adhesive, prior toapplication of the physiological monitoring device to a patient or user.In embodiments, the liner may be separated into two parts, one over eachwing.

In certain embodiments, an additional visualization pattern 710 mayextend through the wing. The visualization pattern 710 may be in anysuitable size or shape to outline the electrode trace and frame theshape of the wings, for example, the visualization pattern 710 may be inthe form of lines, such as rounded lines to reflect the contours of theelectrode trace and the shape of the wings. In certain embodiments,there may be one, two, three, four, or more lines. In some embodiments,the visualization pattern may be formed from a pattern of dots, shapesor other combinations such that the visual cleanliness of the device ismaintained as the otherwise clear adhesive layer becomes less visuallyacceptable to the user through the course of the wear period (e.g. ifthe adhesive layer picks up foreign material and/or becomes cloudy withabsorption of moisture). In certain embodiments, the visualizationpattern may have another functional purpose of alerting the user to howlong they have been wearing the device, for example, by changing colorover time or wearing down. This change in appearance may alert the userto remove the device at the right time. FIG. 6B shows a top view of anembodiment of the physiological device 700, while FIG. 6C shows a bottomview, and FIG. 6D1 depicts a side view. In FIG. 6C, the flexibleelectrodes 712 are visible. As shown in FIG. 6D1, top 714 and bottomhousing 716 portions of the housing may be positioned above and belowthe flexible body 718. FIGS. 6E and 6F show the underside and topside ofthe physiological monitoring device 700, with each layer transparentsuch that all layers are visible. Each layer will be described below ingreater detail in the exploded view of the physiological monitoringdevice 700. Apertures 720, similar to the apertures depicted above inthe embodiments of FIG. 5 , may be positioned in a substrate layerpositioned above the adhesive layer. As described above in greaterdetail, such apertures may provide breathability through one or morelayers and may promote transpiration of moisture from below the adhesivelayer through the layer or layers comprising the apertures. As shown inFIG. 6D2, in embodiments, a gasket 719 may be positioned between theupper housing cover 714 and lower housing 716, co-molded into one ormore of the housings. The gasket may compress down on the adhesiveassembly and a ridged interface (shown below in FIG. 6D2) or anothergasket on the opposite housing to provide waterproofing to the internalelectronics hardware. As depicted in FIG. 6B2, a ridge 721 may bepositioned on an upper edge of the lower housing 716, the ridge 721configured to press into the adhesive layer 719. One of skill in the artwill understand that the ridge 721 may be of any suitable shape, forexample such as an edged ridge as depicted in FIG. 721 . In someexamples, the ridge may be rounded, square, and/or polygonal. In certainexamples, the height of the ridge may be about 0.01 mm to 0.5 mm, about0.05 mm to 0.4 mm, about 0.1 mm to 0.3 mm, about 0.1 mm to 0.2 mm, orabout 0.15 mm such as about 0.13 mm.

FIG. 6G depicts an exploded view of an embodiment of flexible body 701of the physiological monitoring device 700 described herein this sectionand elsewhere in the specification. The housing 706 is not shown. Aswill be understood by one of skill in the art, the image in FIG. 6G isoriented upside down in relation to positioning on the skin. Followingthe numbering within FIG. 6G, #7 depicts a release liner, which protectsthe adhesive layer (240/340 and hydrogel electrodes 350. Directly abovethe adhesive layer are a perforated layer 204 (containing apertures suchas described herein) and a flap layer 203. In certain embodiments, theperforated layer and flap layers may be constructed from any suitablematerial, such as polyethylene terephthalate (PET) and/or polyurethane.Directly above the perforated layer may be a lower substrate layer #1,which may be constructed of polyurethane. In embodiments, the lowersubstrate layer may have at least one textured side, this side may bepositioned such that the textured side faces flap layer #3. Inembodiments, flap layer #3 may also include at least textured side. Thistextured side may be configured to face lower substrate layer #1. Theconductive electrode traces may be printed on an additional, separatesubstrate (311,312). Or, in some embodiments, conductive electrodetraces may be printed directly on the substrate layer #1. Positionedabove the conductive electrode traces may be an upper substrate layer300. Positioned over the upper substrate layer may be an additionalcarrier layer #10, followed by an adhesive layer #11 and a topmost rigidliner #9. One of skill in the art will understand that such anarrangement of layers may be applicable to any embodiment of aphysiological monitor described herein, such as the embodiments of FIG.5H, FIGS. 8A-8D, and FIGS. 6A-6F.

FIG. 6H depicts an exploded view of an embodiment of the housing 706 ofthe physiological monitor device 700, through which passes flexible body701, described in detail above. Top housing cover 714 may include apatient trigger 707. Top housing cover may encase circuit board 722.Spacer 723, positioned below the circuit board, is configured tomaintain consistent spacing between the conductive contact springs thatare on the underside of the circuit board and the battery terminals/ECGtrace contacts. The spacer may additionally provide electricalinsulation between the circuit board and battery. There may be holes inthe spacer to allow conductive contact springs to pass through, thecontact springs connected to the circuit board. Battery terminal 725,may be positioned below the flexible body 701 and circuit boards 722,thereby overlying wave spring 726. In embodiments, the battery terminal725 may be wrapped around and adhered to a coin cell battery 728. Thebattery terminal 725 may be constructed as a flex circuit withconductive vias 727 that enables the positive underside of the coin cellbattery 728 to be brought up to the negative top side of the battery, sothat both the negative and positive terminals are presented on the topside of the battery to meet the circuit board contact springs.Alternatively, a battery contact or contacts in the bottom housing canenable the positive underside of the coin cell battery to be brought upto the negative top side to contact the circuit board. Venting layer 729may be positioned against lower housing portion 716, over a vent hole732 in the lower housing. In embodiments, the venting layer may beconstructed from a material that blocks liquid passage while allowinggas passage, for example ePTFE or any other suitable material. The venthole 732 in combination with the venting layer allows normalization ofair pressure between the outside and inside of the housing. Inembodiments, the vent hole 732 in combination with the venting layerprevents button and/or trigger 707 from blowing out or sucking independing on external air pressure, for example if the patient is at adifferent altitude such as on a plane. The venting layer may be thin andround with adhesive in a ring configuration on the bottom. The area ofthe venting layer coated in adhesive may not be gas permeable, while thecentral portion may be gas permeable but liquid impermeable. The centralportion of the venting layer may be positioned over the vent hole,thereby allowing gas passage into and out of the housing while limitingliquid egress and ingress. In certain embodiments, the venting layer maybe integrated into the bottom housing by molding it in, or it could alsobe ultrasonically welded into the bottom housing, or adhered via anysuitable means.

As shown in FIGS. 7A-7B, in some embodiments, the butterfly flap layer203 may extend directly below the housing 115, 706 (in FIGS. 6A and 5Habove). The non-adhesive top surface of the butterfly flap layer 203 mayprevent the housing from adhering to the butterfly flap. Additionally, acentral portion of the flexible body 110 (e.g. hinge portions 132) maybe configured to float above the skin of the subject and above thebutterfly flap layer 203. FIG. 7A schematically illustrates the profileof a flexible body 110 having hinge lines 134 between which the flexiblebody 110 is configured to lift off the skin of the subject. The adhesivelayer 340 may be adhered to the overlying substrate layers of theflexible body 110 (e.g., bottom substrate layer 330) outside of thehinge lines 134 and adhered to the butterfly flap layer 203 between thehinge lines 134. Figure A illustrates an embodiment where the width ofthe flexible body 110 extends beyond the diameter of the housing 115.FIGS. 7B-7D schematically illustrate various examples of configurationsof adhesive layers 340 comprising butterfly flaps layer 203 designed tobe coupled to the flexible body 110 and to extend underneath the housing115. The shape (e.g., the outer profile) of the adhesive layer 340 maybe configured to mechanically distributed forces across the adhesivelayer 340 in a manner that prevents or inhibits peeling of the adhesivelayer 340 from the skin of the subject in order to promote a longerduration of wear. The outer edges of the adhesive layer 340 may comprisegenerally steep angles, particularly where the outer edge of theadhesive layer 340 intersects the hinge lines 134. The steep angles maybe configured to promote a distribution of stresses through the adhesivelayer 340 that maximize multiple directional vectors of stress, forexample shear and tensile stresses, between the adhesive layer 340 andthe skin of the subject and/or minimizes peel stresses between theadhesive layer 340 and the skin of the subject. Shear stresses andtensile stresses may be less likely to cause separation of the adhesivelayer 340 from the skin. By shifting stress into non-peeling vectors,long-term adhesion may be improved.

For example, FIG. 7B illustrates a flexible body 110 having a profilegenerally resembling an accentuated bowtie, Papillon ears, and/or around dumbbell. The flexible body 110 may comprise a longitudinal axisextending from the outer edge of one of the wings 130, 131 to the outeredge of the other and symmetrically bisecting the two wings 130, 131.The flexible body 110 may have a transverse axis perpendicular to thelongitudinal axis and symmetrically dividing the flexible body 110(e.g., the bottom substrate layer 330), separating the two wings 130,131. The hinge portion 132 of the flexible body of the device 100 mayextend between the hinge lines 134 of the two wings 130, 131. The hingeportion 132 may symmetrically bisect the adhesive layer 340 in thelongitudinal direction. The hinge portion 132 may be narrower in thetransverse direction than the two wings 130, 131. The hinge portion 132may be narrower in the transverse direction than the underlyingsubstrate layers (e.g., butterfly flap layer 203). The outer edge of theflexible body 110 may extend inward toward the longitudinal axis and thetransverse axis from the hinge lines 134. The outer edges may have acurved shape where the outer edges intersect the hinge lines 134. Insome embodiments, the outer edges may each comprise an inflection pointat which the outer edges transition from a convex curvature to a concavecurvature. The concave curvature may be positioned closer to thetransverse axis than convex curvature. The inflection point may bepositioned on the hinge line 134, outside the hinge line 134 (oppositethe transverse axis), or inside the hinge line 134 (same side as thetransverse axis). The curved edge of the adhesive layer 340 where theadhesive layer 340 intersects the hinge line 135 may adjust the vectorof pull away from the edge by changing the angle of the edge as itextends across the hinge line 134, a point where the adhesive layer 340may be particularly prone to peel.

FIG. 7C illustrates another embodiment of a flexible body 110 generallysimilar to that shown in FIG. 7B. However, as shown in FIG. 7C, theflexible body 110 (which may be layered with an adhesive layer) may beconfigured such that the housing 115 may be oriented at an angle offsetfrom the transverse axis with respect to the flexible body 110. Such aconfiguration may allow for the physiological monitoring device 100 tobe worn by the subject at an angle (e.g., FIGS. 9B-9F) while maintainingan alignment of a longitudinal axis of the housing 115 with an axisextending the height of the subject. Any of the embodiments disclosedherein may be modified in the same manner to reorient the housing 115 toaccommodate for an expected orientation of adhesion of the flexible body110 to the subject. FIG. 7D illustrates another configuration of aflexible body 110 including a hinge portion 132 configured to resistpeeling mechanics. The flexible body 110 may comprise an outer profilegenerally having a “z-shaped” configuration or a backwards “z-shaped”configuration, as shown in FIG. 7D. The hinge portion 132 may extendbetween the hinge lines 134. The hinge portion 132 may extend from alower inside corner of the flexible body 110 of one of the two wings130, 131 to an upper inside corner of the flexible body 110 of theopposite wing. In some embodiments, the hinge portion 132 may begenerally linear having a consistent width across a length of the hingeportion 132. In some embodiments, the outer edges of the flexible body110 may be smoothed or somewhat rounded at intersections between thehinge portion 132 and the housing 115 and/or between the hinge portion132 and the portions of the flexible body 110 outside the hinge lines134, as shown in FIG. 7D. Accordingly, there may be no sharp cornersalong the hinge portion 132. The “z-shaped” configuration may reduce thelength of the edges of the flexible body 110 which are aligned withand/or parallel to the hinge lines 134, which may be the edges of theadhesive layer 340 that are most prone to peel. The sharp bends betweenthe hinge portion 132 and the edges along the hinge lines 134 mayincrease the shear forces aligned along the hinge line 134 and reducethe likelihood of peeling, particularly closer to the intersectionbetween the hinge portion 132 and the hinge line 134. This may beachieved by minimizing connection between hinge portion 132 and thecentral housing 115 in situations when the subject's body is in aposition that subjects the patch to torsional forces (as shown in FIG.13B).

In some embodiments, the top substrate layer 300 may be replaced by thesubject at some period of time into the intended wear period, such asabout: 6 hours, 12 hours, 1 day, 2 days, 4 days, 1 week, or a periodlonger than one week, in order to extend duration of wear as well asrefresh the aesthetic appearance of the device. In certain embodimentsthe top substrate layer 300 may exist as two separate pieces withoutintersecting housing 114, as shown in FIG. 6G, each piece can be removedindependently and replaced by new adhesive-backed pieces. The manner ofremoval may be enabled by non-adhesive pull-tab features on substratelayer 300 or other protrusions, whether adhered or not adhered to thesubject's skin. Replacement of top substrate layer 300 with freshadhesive-backed sections may be enabled through similar means as used inthe original application. The top substrate layer 300 may be supportedby a rigid liner and protected by a release liner, where the releaseliner may be removed prior to application and the rigid liner may beremoved after applying to the skin. The top substrate layer 300 may be asingle integral piece, as shown in FIG. 3B, or it may be two or moreseparate pieces, as shown in FIG. 6G. As shown in FIG. 7E, top substratelayer may also be a single integral piece joined in a section that doesnot intersect with housing 115. The top substrate layer 300 may includea thin adhesive layer on its bottom surface, connecting top substratelayer 300 to the other substrates of flexible body 110 and connectingsubstrate layer 300 to the subject's skin along border 133. A bridgeportion 347 may join right and left portions of the top substrate layer300 positioned below the two wings 130, 131. FIG. 7E schematicallyillustrates a bottom view of physiological monitoring devices 100comprising a single top substrate layer 300 comprising a bridge portion347. In some embodiments, the bridge portion 347 may extend around(e.g., a height in the horizontal plane higher than or lower than) acentral portion of the flexible body 110 coupled to the housing 115.FIG. 7E illustrates physiological monitoring devices 100 having bridges347 that extend around the housing 115 in opposite directions. Thebridge portion 347 may comprise a generally curved or arcuate shape. Thetop substrate layer 300 may comprise a “headphone” shape as illustratedin FIG. 7E. The bottom surface of the bridge portion 347 may be adhesivesuch that the bridge portion 347 is configured to adhere to the skin ofthe subject. In some embodiments, the bottom surface of the bridgeportion 347 may not be adhesive such that the bridge portion 347 doesnot adhere to the skin of the subject. The top surface of the bridgeportion 347 may be non-adhesive since it will be exposed when thephysiological monitoring device 100 is worn by the subject.

The arrows in FIG. 7E schematically illustrates a possible preferreddirection of removing the top substrate layer 300, if replaceable, fromthe flexible body 110. The adhesive layer 340 may be removed from one ofthe two wings 130, 131 prior to the other. The adhesive-backed topsubstrate layer 300 may be peeled from the flexible body 110 on a sideopposite the bridge portion 347 (e.g., beginning at an inside corner asdescribed elsewhere herein) and once the adhesive layer 340 is removedfrom one of the wings 130, 131, the adhesive-backed top substrate layer300 may be removed from the other wing 130, 131 by peeling theadhesive-backed top substrate layer 300 from the second wing beginningat where the bridge portion 347 meets the second wing (e.g., beginningat an inside corner). In other implementations, the adhesive-backed topsubstrate layer 300 may be removed from the two wings 130, 131substantially simultaneously by pulling the bridge portion 347 under andacross the bottom surface of the flexible body 110 and the housing 115.In some implementations, the bridge portion 347 may be cut (e.g.,substantially along the center of the bridge 347) creating two free endswhich may be used to peel the adhesive layer 340 from each of the twowings 130, 131.

In some embodiments, placement of adhesive-backed top substrate layer300 may be facilitated through application of a single monolithic piecewithout features or cutouts. This type of layer could be applied overthe top of an entire device 100 for additional securement during wear,or placed after removal of adhesive-backed top substrate layer 300 as areplacement. In other embodiments, the adhesive-backed top substratelayer for additional securement or replacement may be a single piecewith feature cutouts such as shown in FIG. 8D, allowing the housing 115and hinge portions 132 to float free of the skin.

FIG. 7F depicts an embodiment 390 of a wing shape similar to theembodiments of FIGS. 7A-7E. Here, as in FIGS. 5G-5H and 6A-6H, the wingsare asymmetric, with a greater portion of one wing lying above thelongitudinal line and a greater portion of another wing lying below thelongitudinal line. However, here the wings include a sharp notch and ablunted notch 394. The sharp notch may allow the wing to more easilyflex and rotate in a clockwise or counterclockwise direction around a zaxis extending directly through the center of the hole 396.

With reference now to the embodiment of FIG. 9 , upper housing member140 and lower housing member 145 of housing 115 are shown in greaterdetail. Upper and lower housing members 140, 145 may be configured, whencoupled together with gaskets 360, 370 in between, to form a watertightenclosure for containing PCBA 120, battery holder 150, batteries 160 andany other components contained within housing 115. Housing members 140,145 may be made of any suitable material to protect internal components,such as water resistant plastic. In one embodiment, upper housing member140 may include a rigid sidewall and/or hook 440, a light pipe 410 totransmit visual information from the LEDs on the PCBA through thehousing member, a slightly flexible top surface 420, and an innertrigger member 430 extending inward from top surface 420. Top surface420 is configured to be depressed by a patient when the patientperceives what he or she believes to be an arrhythmia or other cardiacevent. When depressed, top surface 420 depresses inner trigger member430, which contacts and activates trigger input 210 of PCBA 120.Additionally, as discussed previously, top surface 420 may have aconcave shape (concavity facing the inside of housing 115) toaccommodate the shape of a finger. It is believed that the design ofupper housing member 140 isolates activation of the trigger input 210from electrodes 350, thereby minimizing artifact in the data recording.

With continued reference to FIG. 9 , lower housing member 145 may beconfigured to detachably connect with upper housing member 140 in such away that housing members 140, 145 may be easily attached and detachedfor reusability of at least some of the component parts of monitoringdevice 100. In some embodiments, a bottom surface 445 (patient facingsurface) of lower housing member 145 may include multiple dimples 450(or “bumps,” “protrusions” or the like), which will contact thepatient's skin during use. Dimples 450 may allow for air flow betweenbottom surface 445 and the patient's skin, thus preventing a seal fromforming between bottom surface 445 and the skin. It is believed thatdimples 450 improve comfort and help prevent a perception in currentlyavailable devices in which the patient feels as if monitoring device 100is falling off when it housing 115 lifts off the skin and breaks a sealwith the skin. In yet another embodiment the bottom surface 445 of lowerhousing member 145 may include multiple divots (recesses instead ofprotrusions, such as shown in FIG. 6C) to prevent a seal from forming.

Referring now to the embodiment of FIG. 10A, battery holder 150 is shownin greater detail. Battery holder 150 may be made of plastic or othersuitable material, is configured to be mounted to PCBA 120 andsubsequently attached to housing 115, and is capable of holding twobatteries 160 (FIG. 1B). In alternative embodiments, battery holder 150may be configured to hold one battery or more than two batteries. Aplurality of protrusions 152 provide a stable platform for batteries 160to be positioned a fixed distance above the surface of PCBA 120,avoiding unwanted contact with sensitive electronic components yetproviding for adequate compression of spring contacts 235 (FIG. 10B).Protrusions 153 lock batteries 160 into position and resist the upwardforce on the batteries from spring contacts 235. Battery holder 150 alsopositions batteries appropriately 160 to provide for adequatecompression of spring contacts 236. Use of battery holder 150 inconjunction with spring contacts 235 and 236 allows for batteries 160 tobe electrically connected to PCBA 120 while still having additionalelectronic components between batteries 160 and PCBA 120 and maintain avery compact assembly. Battery holder 150 may include a flexible hook510 which engages a corresponding rigid hook 440 of upper housing member140. Under normal assembly conditions the flexible hook 510 remainssecurely mated with rigid hook 440. For disassembly, flexible hook 510can be pushed and bent using an appropriate tool passed through tophousing member 140 causing it to disengage from rigid hook 440 andsubsequently allow top housing member 140 to be removed.

With reference now to the embodiments of FIGS. 11A and 11B,physiological monitoring device 100 is shown in side view cross-section.As shown in 6A, physiological monitoring device 100 may include flexiblebody 110 coupled with housing 115. Flexible body 110 may include topsubstrate layer 300, bottom substrate layer 330, adhesive layer 340 andelectrodes 350. Electrode traces 311, 312 are also typically part offlexible body 110 and are embedded between top substrate layer 300 andbottom substrate layer 330, but they are not shown in FIG. 11 . Flexiblebody 110 forms two wings 130, 131, extending to either side of housing115, and a border 133 surrounding at least part of each wing 130, 131.Housing 115 may include an upper housing member 140 coupled with a lowerhousing member 145 such that it sandwiches a portion of flexible body110 in between and provides a watertight, sealed compartment for PCBA120. Upper housing member 140 may include inner trigger member 430, andPCBA may include patient trigger member 210. As discussed previously,lower housing member 145 may include multiple dimples 450 or divots toenhance the comfort of the monitoring device 100.

It is desirable that PCBA 120 is sufficiently rigid to prevent bendingand introducing unwanted artifact into the signal. In certainembodiments, an additional mechanism to reduce and prevent unwantedbending of PCBA 120 may be used. This mechanism is shown in FIG. 11B.Support post 460 is integral to lower housing member 145 and ispositioned directly under patient trigger input 210. During patientsymptom triggering, upper housing member 140 is depressed, engaginginner trigger mechanism and/or member 430 and transmitting a forcethrough patient trigger input 210 into PCBA 120. The force is furthertransmitted through PCBA 120 and into support post 460 without creatinga bending moment, thus avoiding unwanted artifact.

Referring to FIG. 12 , in some embodiments, physiological monitoringdevice 100 may include one or more additional, optional features. Forexample, in one embodiment, monitoring device 100 may include aremovable liner 810, a top label 820, a device identifier 830 and abottom label 840. Liner 810 may be applied over a top surface offlexible body 110 to aid in the application of device 100 to thesubject. As is described in further detail below, liner 810 may helpsupport borders 133 of flexible body 110, as well as wings 130, 131,during removal of one or more adhesive covers (not shown) that coveradhesive surface 340 before use. Liner 810 may be relative rigid and/orfirm, to help support flexible body 110 during removal of adhesivecovers. In various embodiments, for example, liner 810 may be made ofcardboard, thick paper, plastic or the like. Liner 810 typicallyincludes an adhesive on one side for adhering to the top surface ofwings 130, 131 of flexible body 110.

Labels 820, 840 may be any suitable labels and may include producename(s), manufacturer name(s), logo(s), design(s) and/or the like. Theymay be removable or permanently attached upper housing member 140 and/orlower housing member 145, although typically they will be permanentlyattached, to avoid unregulated reuse and/or resale of the device by anunregistered user. Device identifier 830 may be a barcode sticker,computer readable chip, RFID, or the like. Device identifier 830 may bepermanently or removably attached to PCBA 120, flexible body 110 or thelike. In some embodiments, it may be beneficial to have deviceidentifier 830 stay with PCBA 120.

Referring now to the embodiments of FIGS. 13A and 13B, physiologicalmonitoring device 100 may include hinge portions 132 at or near thejuncture of each wing 130, 131 with housing 115. Additionally, each wing130, 131 is typically adhered to the patient via adhesive layers 340,while rigid housing 115 is not adhered to the patient and is thus freeto “float” (for example, move up and down) over the patient's skinduring movement and change of patient position. In other words, when thepatient's chest contracts, housing pops up or floats over the skin, thusminimizing stress on device 100, enhancing comfort, and reducing thetendency of wings 130, 131 to peel off of the skin. The advantageprovided by the combination of the floating rigid housing 115 and theadhered wings 130, 131 is illustrated in FIGS. 13A and 13B. In FIG. 13A,a patient is sleeping, and in FIG. 13B, a patient is playing golf. Inboth examples, monitoring device 100 is squeezed together by thepatient's body, causing housing 115 to float above the skin as wings130, 131 move closer together. This advantage of a floating,non-attached portion of a physiological monitoring device is describedin further detail in U.S. Pat. No. 8,560,046, which was previouslyincorporated by reference.

Referring now to FIGS. 14A-14F, one embodiment of a method for applyingphysiological monitoring device 100 to the skin of a human subject isdescribed. In this embodiment, before the first step shown in FIG. 14A,the patient's skin may be prepared, typically by shaving a small portionof the skin on the left chest where device 100 will be placed and thenabrading and/or cleaning the shaved portion. As shown in FIG. 14A, oncethe patient's skin is prepared, a first step of applying device 100 mayinclude removing one or both of two adhesive covers 600 from adhesivelayers 340 on the bottom surface of device 100, thus exposing adhesivelayers 340. As illustrated in FIG. 14B, the next step may be to applydevice 100 to the skin, such that adhesive layer 340 adheres to the skinin a desired location. In some embodiments, one adhesive cover 600 maybe removed, the uncovered adhesive layer 340 may be applied to the skin,and then the second adhesive cover 600 may be removed, and the secondadhesive layer 340 may be applied to the skin. Alternatively, bothadhesive covers 600 may be removed before applying device 100 to theskin. While adhesive covers 600 are being removed, liner 810 acts as asupport for flexible body 110, provides the physician or other user withsomething to hold onto, and prevents flexible body 110 and borders 133of flexible body 110 from folding in on themselves, forming wrinkles,and so forth. As described above, liner 810 may be made of a relativelystiff, firm material to provide support for flexible body 110 duringapplication of device 100 to the skin. Referring to FIG. 14C, afterdevice 100 has been applied to the skin, pressure may be applied toflexible body 110 to press it down onto the chest to help ensureadherence of device 100 to the skin.

In a next step, referring to FIG. 14D, liner 810 is removed from (forexample, peeled off of) the top surface of flexible body 110. As shownin FIG. 14E, once liner 810 is removed, pressure may again be applied toflexible body 110 to help ensure it is adhered to the skin. Finally, asshown in FIG. 14F, upper housing member 140 may be pressed to turn onphysiological monitoring device 100. This described method is only oneembodiment. In alternative embodiments, one or more steps may be skippedand/or one or more additional steps may be added.

In certain embodiments, when a desired monitoring period has ended, suchas about 14 to 21 days in some cases, a patient (or physician, nurse orthe like) may remove physiological monitoring device 100 from thepatient's skin, place device 100 in a prepaid mailing pouch, and maildevice 100 to a data processing facility. At this facility, device 100may be partially or completely disassembled, PCBA 120 may be removed,and stored physiological data, such as continuous heart rhythminformation, may be downloaded from device 100. The data may then beanalyzed by any suitable method and then provided to a physician in theform of a report. The physician may then discuss the report with thepatient. PCBA 120 and/or other portions of device 100, such as housing115, may be reused in the manufacture of subsequent devices for the sameor other patients. Because device 100 is built up as a combination ofseveral removably coupled parts, various parts may be reused for thesame embodiment or different embodiments of device 100. For example,PCBA 120 may be used first in an adult cardiac rhythm monitor and thenmay be used a second time to construct a monitor for sleep apnea. Thesame PCBA 120 may additionally or alternatively be used with adifferently sized flexible body 110 to construct a pediatric cardiacmonitor. Thus, at least some of the component parts of device 100 may beinterchangeable and reusable.

In further embodiments described in greater detail below, the monitoringdata may be transmitted wirelessly or through other communicationmediums to be analyzed, rather than requiring physical shipment of thedevice for analysis and reporting.

Advantageously, physiological monitoring device 100 may provide longterm adhesion to the skin. The combination of the configuration offlexible and conformal body 110, the watertight, low profileconfiguration of housing 115, and the interface between the two allowsdevice 100 to compensate for stress caused as the skin of the subjectstretches and bends. As a result, device 100 may be worn continuously,without removal, on a patient for as many as 14 to 21 days or more. Insome cases, device 100 may be worn for greater or less time, but 14 to21 days may often be a desirable amount of time for collecting heartrhythm data and/or other physiological signal data from a patient.

In various alternative embodiments, the shape of a particularphysiological monitoring device may vary. The shape, footprint,perimeter or boundary of the device may be circular, an oval,triangular, a compound curve or the like, for example. In someembodiments, the compound curve may include one or more concave curvesand one or more convex curves. The convex shapes may be separated by aconcave portion. The concave portion may be between the convex portionon the housing and the convex portion on the electrodes. In someembodiments, the concave portion may correspond at least partially witha hinge, hinge region or area of reduced thickness between the body anda wing.

While described in the context of a heart monitor, the deviceimprovements described herein are not so limited. The improvementsdescribed in this application may be applied to any of a wide variety ofphysiological data monitoring, recording and/or transmitting devices.The improved adhesion design features may also be applied to devicesuseful in the electronically controlled and/or time released delivery ofpharmacological agents or blood testing, such as glucose monitors orother blood testing devices. As such, the description, characteristicsand functionality of the components described herein may be modified asneeded to include the specific components of a particular applicationsuch as electronics, antenna, power supplies or charging connections,data ports or connections for down loading or off-loading informationfrom the device, adding or offloading fluids from the device, monitoringor sensing elements such as electrodes, probes or sensors or any othercomponent or components needed in the device specific function. Inaddition or alternatively, devices described herein may be used todetect, record, or transmit signals or information related to signalsgenerated by a body including but not limited to one or more of ECG, EEGand/or EMG. In certain embodiments, additional data channels can beinclude to collect additional data, for example, device motion, deviceflex or bed, heart rate and/or ambient electrical or acoustic noise.

The physiological monitors described above and elsewhere in thespecification may further be combined with methods and systems of dataprocessing and transmission that improve the collection of data from themonitor. Further, the methods and systems described below may improvethe performance of the monitors by enabling timely transmission ofclinical information while maintaining the high patient compliance andease-of-use of the monitor described above. For example, the methods andsystems of data processing and transmission described herein thissection of elsewhere in the specification may serve to extend thebattery life of the monitor, improve the accuracy of the monitor, and/orprovide other improvements and advantages as described herein thissection or elsewhere in the specification.

Device Monitoring and Clinical Analysis Platform

The systems and methods described in detail below, in reference to theembodiments of FIG. 15 , may selectively extract, transmit, and analyzeelectrocardiographic signal data and other physiological data from awearable physiological monitor, such as is described above in relationto FIGS. 1 through 14 . The systems and methods described below canimprove the performance of a wearable physiological monitor thatsimultaneously records and transmits data through multiple means. Forexample, selective transmission of extracted data allows for decreasedpower consumption because the wearable patch is not required to transmitall recorded data. By sending extracted data, much of the analysis maybe performed away from the wearable device without requiring fullon-board rhythm analysis, which can also be highly power consumptive,reducing battery life. Further, remote analysis without the powerconstraints inherent to a wearable device may allow for greatersensitivity and accuracy in analysis of the data. Decreased powerconsumption serves to improve patient compliance because it prolongs thetime period between or even eliminates the need for device replacement,battery changes or battery recharging during the monitoring cycle. Bydecreasing battery consumption, longer monitoring times may be enabledwithout device replacement, for example, at least one week, at least twoweeks, at least three weeks, or more than three weeks.

FIG. 15 depicts a general overview of an embodiment of a system 900 forinferring cardiac rhythm information from an R-R interval time series902, as may be generated by a continuous heart rate monitoring device904. The R-R interval time series 902 inputted to the system may includea series of measurements of the timing interval between successiveheartbeats. Typically each interval represents the time period betweentwo successive R peaks as identified from an ECG signal. R peaks arepart of the QRS complex, a combination of three graphical deflectionstypically seen on an ECG, representing the depolarization of the leftand right ventricles of a mammal's heart. The R peak is generally thetallest and most visible upward deflection on an ECG, and thus makes foran appropriate reference point. However, in further embodiments, anycharacteristic ECG fiducial point (such as the QRS complex onset oroffset) may be used in place of the R peak to provide an estimate of theR-R interval time series. The physical characteristics of the monitoringdevice are constructed in such a way as to improve signal fidelity,therefore the high signal fidelity allows for a high level of confidencein accurately extracting R-R peak data.

The R-R interval time series 902 data may be extracted from or receivedfrom a dedicated heart rate monitor such as a heart rate chest strap orheart rate watch, or a wearable health or fitness device 906, 908 thatincorporates heart rate sensing functionality. Alternatively, the R-Rinterval time series 902 may be derived from a wearable patch designedto measure an ECG signal 904 (for instance, by locating the R peaks inthe ECG using a QRS detection algorithm). Furthermore, the R-R intervaltime series 902 may be estimated from an alternative physiologicalsignal such as that obtained from photoplethysmography (PPG). In thisscenario, the peak-to-peak interval time series determined from the PPGsignal may be used as an accurate estimate of the R-R interval timeseries.

In one aspect, a cardiac rhythm inference system 910 is implemented as acloud service or server-based system that exposes an applicationprogramming interface (API) enabling R-R interval time series data orother signal data to be transmitted to the system (for instance, viaHTTP) and the resulting cardiac rhythm information to be returned to thecalling software. The R-R interval time series data 902 or other signaldata may be transmitted to the cloud service directly from theheart-rate monitoring device itself, or indirectly via a smartphone 912,tablet or other internet-enabled communication device 914 that canreceive data from the heart rate monitoring device in either a wirelessor wired manner. In addition, the R-R interval time series data 902 orother signals may be transmitted from a server 916 that stores the datafor a number of users.

In some embodiments, a cardiac rhythm inference system 910 is providedthrough a software library that can be incorporated into a standaloneapplication for installation and use on a smartphone, tablet or personalcomputer. The library may provide identical functionality to that of theinference service, but with R-R interval time series data 902 or othersignal data transmitted directly through a functional call, as opposedto through a web service API.

In certain embodiments, a cardiac rhythm inference system may accept aplurality of R-R interval time series measured from devices of a givenuser 918, in addition to an individual R-R interval time series 902. Inthis scenario, the system computes the frequency and duration of each ofthe cardiac rhythm types inferred from the collection of time seriesdata. These results may then be used to estimate confidence statisticsfor each type of cardiac rhythm based on the frequency and duration ofoccurrence of that rhythm across the various time series. In addition,the rhythm confidence statistics may be updated in a sequential mannerfor each separate call of the inference service. Furthermore, in someembodiments, the cardiac rhythm information inferred by the system maybe provided back to the calling software only in the event that theconfidence score for a given rhythm type exceeds a pre-determinedthreshold value.

In particular embodiments, a cardiac rhythm inference system 910 mayaccept additional sources of data, generally described as alternatesensor channels, in addition to R-R interval time series data, toenhance the accuracy and/or value of the inferred results. Oneadditional source of data includes user activity time series data, suchas that measured by a 3-axis accelerometer concurrently with the R-Rinterval time series measurements. In addition, the system may acceptother relevant metadata that may help to improve the accuracy of therhythm analysis, such as user age, gender, indication for monitoring,pre-existing medical conditions, medication information, medical historyand the like, and also information on the specific day and time rangefor each time series submitted to the system. Furthermore, themeasurement device might also provide some measure of beat detectionconfidence, for example, for each R-Peak or for sequential time periods.This confidence measure would be based on analysis the recorded signalthat, in typical embodiments, would not be recorded due to storage spaceand battery energy requirements. Finally, in the particular case thatthe R-R interval time series data are derived from an ECG signal, thesystem may accept additional signal features computed from the ECG.These features may include a time series of intra-beat intervalmeasurements (such as the QT or PR interval, or QRS duration), or a timeseries of signal statistics such as the mean, median, standard deviationor sum of the ECG signal sample values within a given time period.

The various aspects described above could be used either individually orin combination to provide an application providing insights into anindividual's health, stress, sleep, fitness and/or other qualities.

Some embodiments concern a system for selective transmission ofelectrocardiographic signal data from a wearable medical sensor. Currentwearable sensors, such as the iRhythm ZioPatch™ 904, and furtherdescribed above are capable of recording a single-lead electrocardiogram(ECG) signal for up to two weeks on a single battery charge. In manysituations however, it is desirable for the sensor to be able totransmit, in real-time or near real-time, specific sections of therecorded ECG signal with clinical relevance to a computer device, suchas either a smartphone 912 or an internet-connected gateway device 914for subsequent processing and analysis. In this way, the patient ortheir physician can be provided with potentially valuable diagnostic ECGinformation during the period that the patient wears the sensor.

As described above, a significant challenge with this approach is tomanage the battery life of the wearable sensor without requiringreplacement or recharging, both of which reduce user compliance. Eachtransmission of an ECG from the sensor to a smartphone or local gatewaydevice (using, for example, Bluetooth Low Energy) results in asubsequent reduction in the total charge stored in the sensor battery.Some embodiments of the present disclosure address this issue throughthe use of a novel hardware and software combination to enable theselective transmission of clinically relevant sections of ECG from awearable sensor.

In certain embodiments, the wearable sensor incorporates either asoftware, hardware or hybrid QRS detector that produces a real-timeestimate of each R-peak location in the ECG. The R-peak location data isthen used to compute an R-R interval time series that is subsequentlytransmitted to a smartphone or gateway device according to a predefinedschedule (for example, once per hour). In addition, a time stamp is alsotransmitted which stores the onset time for the R-R interval time seriesrelative to the start of the ECG recording. Since the R-R interval timeseries for a given section of ECG is significantly smaller (in terms ofbytes occupied) than the ECG signal itself, it can be transmitted withconsiderably less impact on battery life.

In some embodiments of a second stage of the system, the R-R intervaltime series together with the onset time stamp is subsequentlytransmitted by the smartphone or gateway device to a server. On theserver, the R-R interval time series is used to infer a list of the mostprobable heart rhythms, together with their onset and offset times,during the period represented by the time series data. The list ofinferred heart rhythms is then filtered according to specific criteria,such that only rhythms matching the given criteria are retained afterfiltering. A measure of confidence may also be used to assist infiltering the events in a manner that might improve the PositivePredictivity of detection.

In certain embodiments of a third stage of the system, for each rhythmin the filtered rhythm set, the server transmits to the smartphone orgateway device the onset and offset time for that specific rhythm. Inthe event that the inferred rhythm duration exceeds a pre-definedmaximum duration, the onset and offset times may be adjusted such thatthe resulting duration is less than the maximum permissible duration.The onset and offset times received by the gateway are then subsequentlytransmitted to the wearable sensor, which in turn transmits the sectionof the recorded ECG signal between the onset and offset times back tothe gateway. This section of ECG is then transmitted to the server whereit can be analyzed and used to provide diagnostic information to thepatient or their physician.

In some embodiments, the system fundamentally allows a device worn forup to about: 14, 21, or 30 days or beyond without battery recharging orreplacement (both activities that reduce patient compliance and,therefore, diagnostic value) to provide timely communication ofasymptomatic arrhythmia events. This development is motivated bytechnology constraints: in order to enable a small, wearable device thatdoes not require battery change or recharging while providing continuousarrhythmia analysis with high accuracy, it is desirable to limit thecomplexity of analysis performed on-board. Similarly, streaming of allof the recorded ECG data to an off-board analysis algorithm may not bepractical without imposing greater power requirements. This motivates amore creative “triage” approach where selected features of the recordedECG signal, including but not limited to R-R intervals, are sent forevery beat, allowing a customized algorithm to locate a number (forexample, 10) of 90-second events to request from the device in fullresolution to support comprehensive analysis, for example, a resolutioncapable of supporting clinical diagnosis.

In other embodiments, the system would provide the ability to detectasymptomatic arrhythmias in a timely manner on a wearable, adhesivelyaffixed device that does not require frequent recharging or replacement.This would be used to enhance the value of some current clinicalofferings, which only provide clinical insight after the recording iscompleted and returned for analysis.

In certain embodiments, the system would allow actionable clinicalinsight to be derived from data collected on low-cost, easy-to-useconsumer wearable devices that are otherwise only focused on fitness andwellness. For example, the technology could be used to create a veryeffective, low-cost screening tool capable of detecting the presence ofAtrial Fibrillation in the at-large population. By using such a tool,not only would patients in need of care be found more easily, but it maybe done earlier and more cost effectively, which lead to betteroutcomes—namely, through reducing stroke risk by identifying AF morequickly.

In particular embodiments, the system may provide the service through adownloadable application that, after receiving customer consent for dataaccess and payment approval, would initiate access and analysis of heartbeat data stored from wearable devices, either stored locally in amobile device or in an online repository. This data pull and analysiswould happen through an Algorithm API, and would result in a clinicalfinding being sent back to the application to be provided to the user.If the data was sufficient to support a “screening oriented” finding,for example, “Likely presence of an irregular rhythm was detected”, theapplication would direct them to a cardiologist where a morediagnostically focused offering, for example, the ZIO® Service, could beprovided to support clinical diagnosis and treatment. In furtherembodiments, as also described elsewhere in the specification, thesystem may trigger an alarm if a particular measurement and/or analysisindicates that an alarm is needed.

Further examples of additional scenarios of clinical value may includecoupling ambulatory arrhythmia monitoring with a blood-alcohol monitorto study the interaction of AF and lifestyle factors. For example,ambulatory arrhythmia monitoring could be coupled with a blood-glucosemonitor to study the impact of Hypoglycemia on arrhythmias.Alternatively, ambulatory arrhythmia monitoring could be coupled with arespiratory rate and/or volume monitor to study the interaction of sleepapnea and breathing disorders. Further, there could be evaluation of thehigh rates of supraventricular ectopic beats as a potential precursorfor AF (for example, 720 SVEs in 24-hour period).

Each of the processes, methods, and algorithms described in thepreceding sections may be embodied in, and fully or partially automatedby, code modules executed by one or more computer systems or computerprocessors comprising computer hardware. The code modules may be storedon any type of non-transitory computer-readable medium or computerstorage device, such as hard drives, solid state memory, optical disc,and/or the like. The systems and modules may also be transmitted asgenerated data signals (for example, as part of a carrier wave or otheranalog or digital propagated signal) on a variety of computer-readabletransmission mediums, including wireless-based and wired/cable-basedmediums, and may take a variety of forms (for example, as part of asingle or multiplexed analog signal, or as multiple discrete digitalpackets or frames). The processes and algorithms may be implementedpartially or wholly in application-specific circuitry. The results ofthe disclosed processes and process steps may be stored, persistently orotherwise, in any type of non-transitory computer storage such as, forexample, volatile or non-volatile storage.

The various features and processes described above may be usedindependently of one another, or may be combined in various ways. Allpossible combinations and subcombinations are intended to fall withinthe scope of this disclosure. In addition, certain method or processblocks may be omitted in some implementations. The methods and processesdescribed herein are also not limited to any particular sequence, andthe blocks or states relating thereto can be performed in othersequences that are appropriate. For example, described blocks or statesmay be performed in an order other than that specifically disclosed, ormultiple blocks or states may be combined in a single block or state.The example blocks or states may be performed in serial, in parallel, orin some other manner. Blocks or states may be added to or removed fromthe disclosed example embodiments. The example systems and componentsdescribed herein may be configured differently than described. Forexample, elements may be added to, removed from, or rearranged comparedto the disclosed example embodiments.

Conditional language, such as, among others, “can,” “could,” “might,” or“may,” unless specifically stated otherwise, or otherwise understoodwithin the context as used, is generally intended to convey that certainembodiments include, while other embodiments do not include, certainfeatures, elements and/or steps. Thus, such conditional language is notgenerally intended to imply that features, elements and/or steps are inany way required for one or more embodiments or that one or moreembodiments necessarily include logic for deciding, with or without userinput or prompting, whether these features, elements and/or steps areincluded or are to be performed in any particular embodiment. The term“including” means “included but not limited to.” The term “or” means“and/or.”

Any process descriptions, elements, or blocks in the flow or blockdiagrams described herein and/or depicted in the attached figures shouldbe understood as potentially representing modules, segments, or portionsof code which include one or more executable instructions forimplementing specific logical functions or steps in the process.Alternate implementations are included within the scope of theembodiments described herein in which elements or functions may bedeleted, executed out of order from that shown or discussed, includingsubstantially concurrently or in reverse order, depending on thefunctionality involved, as would be understood by those skilled in theart.

All of the methods and processes described above may be at leastpartially embodied in, and partially or fully automated via, softwarecode modules executed by one or more computers. For example, the methodsdescribed herein may be performed by the computing system and/or anyother suitable computing device. The methods may be executed on thecomputing devices in response to execution of software instructions orother executable code read from a tangible computer readable medium. Atangible computer readable medium is a data storage device that canstore data that is readable by a computer system. Examples of computerreadable mediums include read-only memory, random-access memory, othervolatile or non-volatile memory devices, CD-ROMs, magnetic tape, flashdrives, and optical data storage devices.

It should be emphasized that many variations and modifications may bemade to the above-described embodiments, the elements of which are to beunderstood as being among other acceptable examples. All suchmodifications and variations are intended to be included herein withinthe scope of this disclosure. The foregoing description details certainembodiments. It will be appreciated, however, that no matter howdetailed the foregoing appears in text, the systems and methods can bepracticed in many ways. For example, a feature of one embodiment may beused with a feature in a different embodiment. As is also stated above,it should be noted that the use of particular terminology whendescribing certain features or aspects of the systems and methods shouldnot be taken to imply that the terminology is being re-defined herein tobe restricted to including any specific characteristics of the featuresor aspects of the systems and methods with which that terminology isassociated.

Various embodiments of a physiological monitoring device, methods, andsystems are disclosed herein. These various embodiments may be usedalone or in combination, and various changes to individual features ofthe embodiments may be altered, without departing from the scope of theinvention. For example, the order of various method steps may in someinstances be changed, and/or one or more optional features may be addedto or eliminated from a described device. Therefore, the description ofthe embodiments provided above should not be interpreted as undulylimiting the scope of the invention as it is set forth in the claims.

Various modifications to the implementations described in thisdisclosure may be made, and the generic principles defined herein may beapplied to other implementations without departing from the spirit orscope of this disclosure. Thus, the scope of the disclosure is notintended to be limited to the implementations shown herein, but are tobe accorded the widest scope consistent with this disclosure, theprinciples and the novel features disclosed herein.

Certain features that are described in this specification in the contextof separate embodiments also can be implemented in combination in asingle embodiment. Conversely, various features that are described inthe context of a single embodiment also can be implemented in multipleembodiments separately or in any suitable subcombination. Moreover,although features may be described above as acting in certaincombinations and even initially claimed as such, one or more featuresfrom a claimed combination can in some cases be excised from thecombination, and the claimed combination may be directed to asubcombination or variation of a subcombination.

Similarly, while operations are depicted in the drawings in a particularorder, such operations need not be performed in the particular ordershown or in sequential order, or that all illustrated operations beperformed, to achieve desirable results. Further, the drawings mayschematically depict one more example processes in the form of a flowdiagram. However, other operations that are not depicted can beincorporated in the example processes that are schematicallyillustrated. For example, one or more additional operations can beperformed before, after, simultaneously, or between any of theillustrated operations. Moreover, the separation of various systemcomponents in the embodiments described above should not be interpretedas requiring such separation in all embodiments. Additionally, otherembodiments are within the scope of the following claims. In some cases,the actions recited in the claims can be performed in a different orderand still achieve desirable results.

1-20. (canceled)
 21. A monitoring device configured to attach to a user,the monitoring device comprising: a housing comprising a processor; awing extending from the housing and configured to conform to a surfaceof a user, the wing comprising: an electrode configured to detect aphysiological signal of the user, the electrode in electricalcommunication with the processor; an adhesive layer coupled to thebottom surface of the wing, the adhesive layer configured to adhere thewearable device to the user; and wherein the wing comprises a firstlayer of a first material comprising perforations through a thickness ofthe first layer and a second layer of a second material configured toform a fluid seal to prevent liquid from the ambient environment fromreaching the adhesive layer.
 22. The monitoring device of claim 21,wherein the adhesive layer comprises a plurality of channels.
 23. Themonitoring device of claim 21, wherein the channels form a lattice. 24.The monitoring device of claim 21, wherein the adhesive layer comprisesa wicking material.
 25. The monitoring device of claim 24, wherein thewicking material is positioned in a channel.
 26. The monitoring deviceof claim 21, wherein the second material comprises polyurethane.
 27. Themonitoring device of claim 21, wherein the perforations are configuredto transmit moisture.
 28. The monitoring device of claim 21, wherein theperforations through the first layer are configured to provide the wingwith anisotropic properties within a plane parallel to a bottom surfaceof the wing.
 29. The monitoring device of claim 21, wherein the wingcomprises a structural reinforcement member.
 30. The monitoring deviceof claim 29, wherein the structural reinforcement member is positionedalong a peripheral edge of the wing.
 31. The monitoring device of claim21, wherein the first layer comprises polyethylene terephthalate. 32.The monitoring device of claim 21, wherein the adhesive layer comprisesa central void.
 33. A monitoring device configured to attach to a user,the device comprising a housing comprising a processor; a wing extendingfrom the housing and configured to conform to a surface of a user, thewing comprising an electrode configured to detect a physiological signalof the user, the electrode in electrical communication with theprocessor; an adhesive layer coupled to the bottom surface of the wing,the adhesive layer configured to adhere the wearable device to the user,the adhesive layer comprising a plurality of channels extending from abottom surface of the adhesive to a top surface of the adhesive, thechannels configured to transport moisture from the surface of the user.34. The monitoring device of claim 33, wherein individual channelsextend in a direction substantially normal to the bottom surface and thetop surface.
 35. The monitoring device of claim 33, wherein the channelsare substantially arranged in an array.
 36. The monitoring device ofclaim 33, further comprising a void positioned in a central portion ofthe adhesive layer.
 37. The monitoring device of claim 33, wherein thechannels are arranged in a lattice.
 38. The monitoring device of claim37, wherein the adhesive layer comprises adhesive islands separated bychannels, the adhesive islands connected by a web.
 39. The monitoringdevice of claim 33, wherein the channels are arranged in a radialpattern.
 40. The monitoring device of claim 33, wherein the adhesivelayer further comprises an wicking material.